Primary Care Coding Alert

Question: During a recent follow-up appointment with an established patient, the patient explained they didn’t get their prescribed medication because it was too expensive, and their insurance wouldn’t cover the medication. Should I report this as a social determinant of health?

New York Subscriber

Answer: Yes, you can assign a social determinant of health (SDoH) code to report that the patient is not adhering to the treatment plan. The ICD-10 code set includes several SDoH codes that could pertain to the patient’s situation.

According to the April 2023 updated ICD-10 Official Guidelines, section I.C.21.c.17, “Social determinants of health (SDOH) codes describing social problems, conditions, or risk factors that influence a patient’s health should be assigned when this information is documented in the patient’s medical record. Assign as many SDOH codes as are necessary to describe all of the social problems, conditions, or risk factors documented during the current episode of care.” This means that you’ll assign any SDOH codes that are needed to accurately depict associated problems, conditions, or risk factors for that patient’s care during the current encounter.

Note: Review the updated ICD-10 Official Guidelines at www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf.

Depending on what information is included in the medical documentation, you could choose from any of the following codes:

• Z59.5 (Extreme poverty)
• Z59.6 (Low income)
• Z59.7 (Insufficient social insurance and welfare support)
• Z59.86 (Financial insecurity)
• Z59.89 (Other problems related to housing and economic circumstances)
• Z91.120 (Patient’s intentional underdosing of medication regimen due to financial hardship)

If the provider’s documentation states the patient didn’t fill the prescription due to financial reasons, you’ll definitely want to code Z91.120. Take note that parent code Z91.12- (Patient’s intentional underdosing of medication regimen) also features a Code first note instructing you to assign a code from T36-T50 with “6” as the 5th or 6th character to report the underdosing of the specific medication. For example, if the medication in question was penicillin, you would code first T36.0X6 (Underdosing of penicillins), followed by Z91.120.