Last Chance to Capture SDOH for 2025

By now, you are probably well aware that CMS has chosen to audit records starting with 2018 and going through 2025, and they will continue to audit on an annual basis.

While unfortunately there is no way to go back in time and correct missed opportunities or coding errors, there is still time to capture the required Social Determinants of Health (SDOH) questions for 2025.

CMS requires more frequent and standardized screening across Medicare and Medicaid programs to ensure social risk factors are consistently identified. Healthcare providers MUST collect data on:

• • Food insecurity
  • Housing insecurity
  • Interpersonal safety
  • Transportation insecurity
  • Utilities

Medicare covers one SDOH risk assessment every six months.

This applies when using CPT code G0136 for a standardized, evidence-based SDOH risk assessment. However, if it is apparent your patient is experiencing difficulty in this area, you should collect the information as needed and provide resources (or at least the number for Member Services on the back of their insurance card).

Insecurity in any of these areas will ultimately affect a person’s health. Think of it in these terms:

• • Transportation can hinder getting to appointments or having labs drawn.
  • Financial insecurity is most likely the root of all other insecurities, and ultimately this can cause a delay in acquiring medications.

We at HealthTeam Advantage know you’re doing the work. Just be sure the work you are doing is noted in the medical record! We can’t go back and change the past, but we can all work toward a better future.

A friendly reminder: Even if you are not the physician treating a patient’s condition, you should be aware of all conditions the patient is currently under treatment for. A prime example would be mental health. If a patient is currently under treatment for this, it should be documented on the record along with any medications they may be receiving as treatment.

3 Phrases that Cause Coding Errors

Are you aware of the three documentation phrases that cause frequent coding errors?

1. 1. “History of” — Is it actually a history of, or does it remain under control and the patient is still receiving treatment (i.e. cancer)?
   2. “Likely” — This is not definitive and leaves the condition open to suspect.
   3. “Consistent with” — When uncertain terminology appears in the assessment and plan in the physical exam, coders cannot accurately assign a specific code. This then can lead to coding that does not support the patient’s future treatment plan.

Coding Tips

The principal purpose of a medical coder’s position in a provider’s office is to accurately translate patient documentation into standardized alphanumeric codes for billing, insurance, and record-keeping process. To be able to follow through on this, it is paramount that a coder remains current with any changes in codes.

Here is an overview of what has changed as of October 1, 2025:

KEY CHANGES FOR ICD-10-CM (DIAGNOSIS CODES)

• • Sixteen new R codes
  • New code R11.16 Cannabis hyperemesis syndrome
  • Five new codes for reporting specificities of costovertebral (angle) with specificity
  • New Z codes to show more context regarding Social Determinants of Health
  • Significant changes affecting oncology coding
  • Emergency Department coding updates
  • Multiple Sclerosis changes
  • New codes for congenital malformations
  • New parent code related to neurodevelopment disorders related to a patient’s genetics
  • New eye conditions diagnosis codes
  • Musculoskeletal modifications
  • New Genito urinary codes
  • Fluoroquinolone Adverse Effect codes