Otolaryngology Coding Alert

• Availability of resources (i.e., safe housing, transportation, local food stores)
• Access to educational and job opportunities
• Circumstances affecting access to healthcare
• Exposure to crime, violence, and social disorder
• Social norms and attitudes (i.e., discrimination, racism, criminal justice climate)

All of these things factor into a patient’s overall picture of health or lack thereof. Although these types of determinants may be documented within the medical record, they have not always been coded. Now more than ever, it is imperative that they be reported.

Step 2: Recognize the Importance of Reporting Codes Z55-Z65

Social determinants influence health in very direct ways, and SDoH codes allow you to paint the full picture of the external influences on a patient’s condition and enable your provider to tailor patient treatment accordingly.

More, “when the patient’s SDoH status affects the care of the patient, these status codes can better show the complexity of the patient population you serve,” according to JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis.

Step 3: Understand SDoH Reporting

You’ll find all the codes for reporting SDoH in the Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) group of codes:

• Z55.- (Problems related to education and literacy)
• Z56.- (… employment and unemployment)
• Z57.- (Occupational exposure to risk factors)
• Z59.- (Problems related to housing and economic circumstances)
• Z60.- (… social environment)
• Z62.- (… upbringing)
• Z63.- (Other problems related to primary support group, including family circumstances)
• Z64.- (Problems related to certain psychosocial circumstances)
• Z65.- (… other psychosocial circumstances)

Do this: Before using these codes, familiarize yourself with the main ICD-10-CM guideline that governs their use. Per I.B.14, codes in categories Z55-Z65 “should only be reported as secondary diagnoses.” Additionally, Z55-Z65 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.

Step 4: Preview New SDoH Codes and Guidance

The first significant revision in this section of ICD-10-CM for 2023 is the expansion of the Z59.8- (Other problems related to housing and economic circumstances) code set, which will allow you to capture ways in which a patient’s health is affected by their social circumstances in much greater detail when the codes become effective.

This update “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, in Centennial, Colorado.

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

The three new codes and their inclusion terms are:

• 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.

In addition, ICD-10-CM 2023 contains new Excludes2 notes stating you can code extreme poverty (Z59.5), low income (Z59.6), or material hardship NEC (Z59.87) with Z59.86 and extreme poverty (Z59.5), financial insecurity (Z59.86), and low income (Z59.6) with Z59.87.

Step 5: Learn Proper Application of SDoH Codes

Note that ICD-10-CM 2023 has also expanded guideline I.C.21.c.17 to help you use the codes effectively. This change is significant, as it removes an apparent contradiction within ICD-10-CM guidelines and between ICD-10 and CPT^® guidelines, according to Wolf.

“ICD-10 guideline IV.J. states that we should ‘Code all documented conditions that coexist at the time of the encounter/ visit and that require or affect patient care treatment or management,’” Wolf notes. Similarly, the recent revisions to the office/outpatient evaluation and management (E/M) guidelines include SDoH as a moderate risk level of medical decision making (MDM), but only when “the treatment is ‘significantly limited’ by SDoH in order for SDoH to be considered,” Wolf adds.

The guideline expansion will help you determine the number and relevance of codes you should use on a patient’s record, telling you to assign SDoH codes “when the documentation specifies that the patient has an associated problem or risk factor.” To clarify, the guideline provides the example that “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 their ability to take care of themselves.

Keep in mind: Simply listing a SDoH is not sufficient to get credit in the moderate risk category for the E/M service. The provider must document how the social determinant affects patient management.