AHIMA August 23, 2021
As of January 1, 2021, there are new Evaluation and Management (E/M) Services Guidelines for outpatient and ambulatory services that encompass specific areas of risk defined in the social determinants of health (SDOH). Professional fee coding auditors often review records with templates that have no data, as shown below in a chart captured from an Epic template. Electronic health record (EHR) analysts sometimes proactively add these items; however, in order to convey the full picture of the patient’s circumstances, the data must be complete.
SDOH elements are specifically utilized in accordance with a Level 4 service, as defined in the risk section of the 2021 American Medical Association (AMA) guidelines from the organization’s rollout presentation. An example from that AMA...
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