Primary Care Coding Alert

Last month, in issue 25, number 8 of Primary Care Coding Alert, we reported that 501 new codes go into effect starting Oct. 1, 2023. Among them are a handful of new codes that represent social determinants of health (SDoH).

As promised, here is a guide to help you better understand why and how to use SDoH codes.

Tip 1: Review the Meaning of “SDoH”

“Social determinants of health are 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,” according to the Office of Disease Prevention and Health Promotion (ODPHP). They include such factors as “availability of resources to meet daily needs (e.g., safe housing and local food markets), access to educational, economic, and job opportunities, exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community), [and] socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)” (Source: www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health).

Tip 2: Report SDoH Because it’s Integral, Not Required

While there may not be any legal mandates for reporting the Z55-Z65 codes, there are some very good reasons for doing so. This is because 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.

Moreover, “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. In other words, SDoH codes can enable you to communicate a better, more comprehensive understanding of the social context in which your practice’s patients find themselves.

Tip 3: Understand How to Report SDoH

You’ll find the available codes to report SDoH in the Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) group of codes. Many of the key codes you might need for reporting SDoH can be found in the following code groups:

• Z55.- (Problems related to education and literacy)
• Z59.- (Problems related to housing and economic circumstances)
• Z60.- (Problems related to social environment)
• Z62.- (Problems related to upbringing)
• Z63.- (Other problems related to primary support group, including family circumstances)

Expert coding tip: Before using one of the Z55-Z65 codes, be sure you become familiar with the main ICD-10 guideline that governs their use. Per guideline 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 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 in section I.C.21.c.17 go on to elaborate.

So, 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, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider,” per ICD-10 Official Guidelines.

Tip 4: Sneak a Peek at How the SDoH Guidelines Are Changing in 2024

ICD-10 is adding information to their SDoH guideline again, this time with two significant paragraphs, which you’ll find at the top of Section 1.C.21.c.17. Starting in Oct. 2023, the section will start off with a more detailed explanation of what SDoH means and an instruction to assign any and all SDoH that the provider documents. Several helpful examples are included, including the following: “For example, a patient who lives alone may suffer an acute injury temporarily impacting their ability to perform routine activities of daily living. When documented as such, this would support assignment of code Z60.2, Problems related to living alone. However, merely living alone, without documentation of a risk or unmet need for assistance at home, would not support assignment of code Z60.2.”

Documentation note: The new guidelines go on to stress the importance of clinical documentation, either by a clinician or as reported by the patient or the patient’s guardian and then signed off by the clinician. “Coders need to be aware of documentation in the record in an effort 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.