Pediatric Coding Alert

Question: My provider counseled a 7-year-old patient and their father about adverse changes in the child’s behavior due to the absence of his mother. Elsewhere in the patient’s chart, I can see that a social worker has documented that the child’s mother has deployed on military duty. This information is not in the provider’s notes, though. Can I assign a Z code to this encounter and, if so, which one?

Georgia Subscriber

Answer: Even though your provider has not documented the mother’s active military status, you can still go ahead and code Z63.31 (Absence of family member due to military deployment).

That’s because ICD-10 guideline B.14 states that social determinants of health (SDoH), such as information found in codes Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.

Note: Remember that SDoH can affect medical decision making (MDM). This situation outlined above presents a good opportunity to educate the provider. If the documentation states the reason for the absence, that could contribute to the risk and complication and/ or morbidity and mortality when leveling future encounters.