General Surgery Coding Alert

Question: Our surgeon is treating a patient with diverticulosis, and the primary care physician wrote down that the patient is noncompliant with their diet regimen. Is this something I should report? How do I know when I should be reporting SDoH codes?

Texas Subscriber

Answer: Clinicians should be documenting social determinants of health (SDoH), and in general, you should be coding them. By accurately documenting SDoH, healthcare providers can better understand the factors affecting a patient’s health, leading to improved care management, resource allocation, and health outcomes.

When you notice potentially applicable SDoH in a patient’s medical record, ask yourself the following questions to determine whether their corresponding codes belong in the claim:

• Is the SDoH relevant to the patient’s health condition and been documented by the provider?
• Does the SDoH have a direct impact on the patient’s healthcare management, treatment plan, or outcomes?

If you can answer “yes” to these questions, you should include SDoH codes on the claim.

Your example checks both those boxes. If a diverticulosis patient is noncompliant with a recommended dietary regimen, specifically a high fiber diet, it could lead to waste buildup and constipation which puts pressure on the diverticula, putting the patient at risk of more serious illness.

Keep in mind: The primary care physician is not the only one who can document a patient’s SDoH. Per ICD-10-CM guideline I.B.14, Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) are some of the only codes that you can report “based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider.” That’s because “this information represents social information, rather than medical diagnoses,” as the guidelines go on to elaborate.

So, you can use documentation “from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record,” and “patient self-reported documentation … to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider,” per ICD-10-CM Official Guidelines.