General Surgery Coding Alert

ICD-10-CM:

Know When and How to Use New SDoH Codes

Published on Mon Sep 19, 2022

Make sure to report social factors that impact care.

When your surgeon notes that issues related to social considerations or care compliance impact a patient’s healthcare, you’ll have new codes to report the situation beginning Oct. 1.

That’s because the 2023 ICD-10-CM update includes new “Z” codes that identify some social determinants of health (SDoH). Here’s the intel on these codes that you can add to our prior introduction to new ICD-10-CM codes in “Keep Medical Necessity Accurate With New Dx Codes,” (General Surgery Coding Alert Vol 24 No 8).

Follow Guideline Changes For Best Practices

ICD-10 2023 has expanded guidelines to explain how to use the new SDoH codes effectively.

Key: According to I.C.21.c.17, the purpose of reporting SDoH codes is to identify and report the “problems or risk factors” that impact healthcare. You shouldn’t report one of the codes if the social factor is not relevant to the patient’s health and care compliance. For instance, the guidelines state, “not every individual living alone would be assigned code Z60.2 [Problems related to living alone].” The documentation must specifically show that the patient has a health problem or risk factor associated with living alone.

Capture all: Revised ICD-10-CM guideline IV.J states that you should “code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care treatment or management.”

Remember: The 2021 ICD-10-CM revisions to the office/ outpatient E/M guidelines include SDoH as a moderate risk level of medical decision making (MDM), but only when it’s clear that SDoH has a significantly limiting influence on the treatment.

Financial impact: Properly reporting SDoH can affect MDM level and thus, E/M code selection, which in turn will impact your payment. In many managed care systems, providers and payers have payment contracts based on risk assessment data related to SDoH. “Generally, individuals who carry one or more of a range of high-risk diagnoses have higher capitation paid on their behalf, so managed care plans are motivated to have providers report these diagnoses,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, former CPT® Editorial Panel member in Pasadena, California.

More guidance: ICD-10-CM 2023 revises I.C.19.e.5.(c) to state that “documentation of a change in the patient’s condition is not required in order to assign an underdosing code. Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment.” That means you can go ahead and report the appropriate code from the range T36.- to T50.- (Poisoning by, adverse effects of and underdosing of drugs, medicaments and biological substances) even if there is no change in the patient’s condition. Then you should also report the factors influencing health such as Z91.12- (Patient’s intentional underdosing of medication regimen) or one of the new caregiver codes introduced below.

Who assigns: “Per ICD-10-CM guideline I.B.14, other clinicians such as nursing staff may document SDoH, and this information can be captured by the coder. With more SDoH codes being implemented, coders need to be mindful of nursing documentation in an effort to capture these important codes,” says Chelsea Kemp, RHIT, CCS, COC, CDEO, CPMA, CRC, CCC, CEDC, CGIC, AAPC Approved Instructor, outpatient coding educator/auditor for Yale New Haven Health, New Haven, Connecticut.

Get Ready for Z59.8- Code Expansion

By expanding Z59.8- (Other problems related to housing and economic circumstances), ICD-10-CM 2023 allows you to capture in greater detail what social circumstances may be impacting a patient’s health.

The three new codes and their inclusion terms are as follows:

Z59.82 (Transportation insecurity) — Includes excessive transportation time along with inaccessible, inadequate, lack of, unaffordable, unreliable, and unsafe transportation
Z59.86 (Financial insecurity) — Includes bankruptcy, burdensome debt, economic strain, financial strain, money problems, running out of money, unable to make ends meet
Z59.87 (Material hardship) — Includes material deprivation, and inability to obtain adequate childcare, adequate clothing, adequate utilities, and basic needs

This expansion “now allows for further specificity when coding for other problems related to housing and economic circumstances,” notes Amy Pritchett, CCS, CPC-I, CPMA, CDEO, CASCC, CANPC, CRC, CDEC, CMPM, C-AHI, senior consultant at Pinnacle Enterprise Risk Consulting Services LLC, Centennial, Colorado.

“Prior to the expansion of Z59.8, everything rolled into the ‘other’ code. But the addition of a 5th digit (2, 6, 7) allows you to document transportation insecurity, financial insecurity, and material hardship,” Pritchett adds.

More: ICD-10 2023 also contains a new Excludes2 note indicating that you can code extreme poverty (Z59.5), low income (Z59.6), or material hardship NEC (Z59.87) with Z59.86 and Z59.87.

Use New Patient and Caregiver Noncompliance Codes

ICD-10 2023 expands the patient noncompliance codes, so you’ll now be able to report various reasons for a patient’s inability or unwillingness to follow medical treatment with the following new codes:

Z91.110 (Patient’s noncompliance with dietary regimen due to financial hardship)
Z91.118 (Patient’s noncompliance with dietary regimen for other reason)
Z91.119 (Patient’s noncompliance with dietary regimen due to unspecified reason)
Z91.190 (Patient’s noncompliance with other medical treatment and regimen due to financial hardship)
Z91.198 (Patient’s noncompliance with other medical treatment and regimen for other reason)
Z91.199 (Patient’s noncompliance with other medical treatment and regimen due to unspecified reason)

Caregiver: If the non-compliance is due to the caregiver for a child or elderly patient, for example, and not the patient, you’ll have new codes to capture that situation, beginning Oct. 1. Under new category, Z91.A- (Caregiver’s noncompliance with patient’s medical treatment and regimen), you’ll find several analogous codes to the patient noncompliance codes, including Z91.A10 (Caregiver’s noncompliance with patient’s dietary regimen due to financial hardship) and Z91.A9 (Caregiver’s noncompliance with patient’s other medical treatment and regimen).

Plus: Z91.A- also adds significant new codes that provide greater specificity for caregiver noncompliance, such as the following:

Z91.A20 (Caregiver’s intentional underdosing of patient’s medication regimen due to financial hardship)
Z91.A28 (Caregiver’s intentional underdosing of medication regimen for other reason)
Z91.A3 (Caregiver’s unintentional underdosing of patient’s medication regimen)
Z91.A4 (Caregiver’s other noncompliance with patient’s medication regimen)

Prior to the addition of these codes, you could document these situations only with a non-specific code for “other noncompliance,” according to Pritchett.