Ob-Gyn Coding Alert

Question: Should I be reporting every social determinant of health (SDoH) that applies to the patient?

New Jersey Subscriber

Answer: While it is certainly good coding practice to use as many SDoH codes as possible to fully document the effects of external factors on a patient’s health, ICD-10-CM guideline I.C.21.c.17 helps you determine the number and relevance of codes you should use on a patient’s record. The guideline tells you to assign SDoH codes “when the documentation specifies that the patient has an associated problem or risk factor.”

To clarify, the guideline uses the following example: Not every individual living alone would be assigned code Z60.2 (Problems related to living alone). You would only use that code if the patient’s solitary life limited the patient’s ability to take care of their health.