Oncology & Hematology Coding Alert

Know the who, why, and what behind this critical new coding development.

By now, most of us in the coding community have a good understanding of the social determinants of health (SDoH), those “conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.” They include such things as the “availability of resources to meet daily needs (e.g., safe housing and local food markets) … access to educational, economic, and job opportunities … access to health care services, quality of education … transportation options … social support … socioeconomic conditions … [and] language/literacy,” according to the Office of Disease Prevention and Health Promotion (ODPHP) (https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health).

But when it comes to using ICD-10-CM codes to document patients whose health and prognoses are directly affected by external social and economic forces, our understanding may be lacking. That’s why many myths have sprung up regarding the assignment of codes (Z55-Z65) (Persons with potential health hazards related to socioeconomic and psychosocial circumstanc­es). So, it’s about time we busted them, not only to increase our coding accuracy, but also to help improve our patients’ wellbeing.

Myth 1: You Don’t Have to Report SDoH Codes

Reality: This myth is actually true, with one new and important exception, which we’ll explain below.

However, even though there are currently no local, state, and national level mandates for reporting a SDoH code from Z55-Z65 in a patient’s chart in the outpatient setting, there are plenty of other good reasons for doing so.

First, the codes are a powerful tool used to generate data at the practice, local, state, and national levels for:

• “Empowering providers to identify and address health disparities (e.g., care coordination and referrals)
• ‘Supporting quality measurements [such as the Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare Stars program]
• ‘Supporting planning and implementation of social needs interventions
• ‘Identifying community and population needs
• ‘Monitoring SDOH intervention effectiveness for patient outcomes …”
• And “updating and creating new policies” (Source: Centers for Medicare & Medicaid Services (CMS): www.cms.gov/files/document/cms-2023-omh-z-code-resource.pdf).

Additionally, you can use the codes to help justify the level of medical decision making (MDM) in certain office/ outpatient evaluation and management (E/M) encounters. The table of MDM elements for office/outpatient evaluation and management codes 99202-99205/99212-99215 (Office or other outpatient visit for the evaluation and management of a new/ established patient, which requires a medically appropriate history and/or examination …) lists SDoH as an example of a moderate-level risk of complication/morbidity.

So, when your provider notes that one or more SDoH element “significantly limits” a patient’s diagnosis or treatment (for example, a patient’s economic circumstances inhibit their ability to pay for a drug treatment, or their lack of transportation affects their ability to attend appointments), then you can use the information to assign a moderate MDM morbidity risk level to the encounter.

The inpatient exception: The Centers for Medicare & Medicaid Services (CMS) is now requiring acute care hospitals enrolled in its hospital Inpatient Quality Reporting (IQR) Program to report SDoH, according to Amy Pritchett, AAPC Fellow, RAP, CRC, CPA-RA, CCS, CPC, CPMA, CPCO, CDEO, CDEC, CANPC, CASCC, CMPM, AAPC Approved Instructor, senior manager HCC coding/audit & education services for Pinnacle Healthcare Consulting, Denver, Colorado.

Under the program, patients who are admitted to such a hospital and who are 18 or older on the date of admission, should be screened for “five health related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety during their hospital inpatient stay.” Hospitals in the program must then capture the information, and can use the appropriate ICD-10-CM SDoH code to do so (https://www.qualityreportingcenter.com/globalassets/2023/04/iqr/sdoh-measure--faqs_vfinal_04012023508.pdf).

Myth 2: You Can Only Report SDOH Codes Documented by the Patient’s Provider

Reality: This is a myth, as codes in the Z55-Z65 range are some of the only codes in ICD-10-CM 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.

However, there is a caveat. While 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,” patient self-reported information must be “signed-off by and incorporated into the medical record by either a clinician or provider” per ICD-10-CM guideline I.C.21.c.17.

In fact, whenever you report an SDoH code, you must make sure there is “documentation in the record … to capture and report these social determinants of health. Codes need supporting documentation that indicate a risk or concern by the practitioner,” emphasizes 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.

Myth 3: You Should Report Every SDoH Code That Applies to the Patient

Reality: 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.

Myth 4: You Can Report SDoH Codes as Primary Diagnoses

Reality: This is purely a myth. ICD-10-CM guideline I.B.14 tells you simply that codes in categories Z55-Z65 “should only be reported as secondary diagnoses.”

Myth 5: You Can Only Report 1 SDoH Code Per Patient Encounter

Reality: This is also a myth, which is easily refuted by ICD-10-CM guideline I.C.21.c.17. The guideline instructs you to “assign as many SDOH codes as are necessary to describe all of the social problems, conditions, or risk factors documented during the current episode of care.”