Pediatric Coding Alert

Also, take note of these related guideline changes.

Documenting social determinants of health (SDoH) has become easier over the last few years thanks to the steady increase in the number of ICD-10 codes available to include in the patient’s medical record.

The 2023 edition of ICD-10 increases those options. But further additions to the new encounter codes, which become effective on Oct. 1, 2022, will also allow you to document two other important factors that adversely affect patient wellbeing: patient and caregiver noncompliance.

Here is your first look at the new codes, along with some expert analysis to help you add them to your coding arsenal.

Get Ready for SDoH Code Expansion

The first significant revision of note is the expansion to 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.

This expansion “now 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)

Additionally, “ICD-10 2023 contains a new Excludes2 note stating you can code extreme poverty [Z59.5], low income [Z59.6] or material hardship NEC [Z59.87] with Z59.86 and Z59.87,” Pritchett observes.

Know How to Apply SDoH Codes

ICD-10 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 guidelines and between ICD-10 and CPT^® guidelines, according to JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis.

“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 now 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 the patient’s ability to take care of themselves.

Comply With These New Patient and Caregiver Noncompliance Codes

ICD-10 2023 also expands the patient noncompliance codes. You’ll now be able to report various reasons for a patient’s inability or unwillingness to follow medical treatment with the following new codes:

• Z91.110 (Patient’s noncompliance with dietary regimen due to financial hardship)
• Z91.118 (Patient’s noncompliance with dietary regimen for other reason)
• Z91.119 (Patient’s noncompliance with dietary regimen due to unspecified reason)
• Z91.190 (Patient’s noncompliance with other medical treatment and regimen due to financial hardship)
• Z91.198 (Patient’s noncompliance with other medical treatment and regimen for other reason)
• Z91.199 (Patient’s noncompliance with other medical treatment and regimen due to unspecified reason)

Of special note to pediatric coding, though, are “a new category of codes that allow for the assignment of caregiver noncompliance and reasons for such compliance,” which you could only document previously with a code for “other noncompliance,” according to Pritchett.

Under this new category, Z91.A- (Caregiver’s noncompliance with patient’s medical treatment and regimen), you’ll find several analogous codes to the patient noncompliance codes, including Z91.A10 (Caregiver’s noncompliance with patient’s dietary regimen due to financial hardship) and Z91. A9 (Caregiver’s noncompliance with patient’s other medical treatment and regimen).

But Z91.A- also adds significant new codes that provide greater specificity for caregiver noncompliance, such as:

• Z91.A20 (Caregiver’s intentional underdosing of patient’s medication regimen due to financial hardship)
• Z91.A28 (Caregiver’s intentional underdosing of medication regimen for other reason)
• Z91.A3 (Caregiver’s unintentional underdosing of patient’s medication regimen)
• Z91.A4 (Caregiver’s other noncompliance with patient’s medication regimen)
• Z91.A5 (Caregiver’s noncompliance with patient’s renal dialysis)

Don’t Overlook This New Underdosing Guideline

ICD-10 2023 also contains an addition to the wording of underdosing guideline I.C.19.e.5.(c), which will affect the way you assign both new codes Z91.A28 and Z91.A3 along with the numerous other underdosing codes currently found throughout ICD-10.

The new wording states that “documentation of a change in the patient’s condition is not required in order to assign an underdosing code. Documentation that the patient is taking less of a medication than is prescribed or discontinued the prescribed medication is sufficient for code assignment.”

So, the medical record simply needs to show the patient is not taking the prescribed dose of a medication, not that underdosing is adversely affecting the patient’s condition. Under such circumstances, you can then go ahead and code T36-T50 for the underdosing, along with the appropriate noncompliance (Z91.12-, Z91.13- and Z91.14-) or complication of care (Y63.6-Y63.9) code(s) per the current guideline.

Remember: Also, per the existing guideline, you should not assign an underdosing code as a principal or first-listed code “if a patient has a relapse or exacerbation of the medical condition for which the drug is prescribed because of the reduction in dose.” In such cases, the guideline instructs you to code the patient’s medical condition as the first-listed code.