Otolaryngology Coding Alert

Reader Questions:

Learn the Importance of SDOH

Published on Mon Jul 15, 2024

Question: There’s a huge push to document social determinants of health (SDOH) for patients, but I don’t understand the point. The practice where I work sees a lot of folks who are struggling. It feels like we’re robbing them of dignity to talk about it in their medical records. Why do we have to record that information?

Ohio Subscriber

Answer: Documenting SDOH via ICD-10 codes is an important part of helping payers and other organizations determine a population’s well-being, said Kimberly Jolivette Williams, CPCO, CPC, CPB, CPMA, CANPC, CCC, CEMC, CEO and senior instructor at Jolivette MediCoding Institute LLC, in a presentation during AAPC’s REVCON.

Reporting SDOH with ICD-10 codes also impacts the appropriate allocation of funding for government-specific disease management programs.

Examples of SDOH that could influence health outcomes include healthcare access, financial security, education, housing, nutrition and food security, social support, cultural and social norms, work, transportation, and childhood stress.

Coders can contribute to the data collection about childhood poverty within a single practice, for example, and thus help influence big-picture relief measures for that issue across the country.

SDOH are not moral judgments of a person’s success in life, and recording such conditions simply provides context about how a person is living and what obstacles they might face.

Keep in mind: If providers use SDOH as a risk factor in medical decision making (MDM) when scoring the level of evaluation and management (E/M), the documentation must include how the SDOH affects the treatment plan and/or ability of the provider to care for the patient. If they just list an SDOH but do not indicate how it affects the patient and their care plan, the SDOH should not be included in the risk assessment calculation for a patient’s E/M level.