Coding SDOH Takes Practice
Why it’s so important to capture social determinants of health in the medical record.
Social determinants of health (SDOH) are “those conditions in which people are born, grow, live, work, and age, as well as the complex, interrelated social structures and economic systems that shape these conditions,” according to the Centers for Disease Control and Protection (CDC). These factors were included in the Healthy People objectives, which are a series of data-driven national goals to improve health by 2030.
ICD-10-CM codes are a fundamental part of formulating statistics and identifying populations with certain diseases. In addition, this diagnostic information is crucial in allocating funds to government-specific disease management programs. Healthcare providers and health plans also use this diagnostic data when rolling out disease management initiatives such as diabetes educational sessions in communities.
The classification also incorporates Z codes that capture other factors influencing health and medical services. These codes include social data for what goes on outside the provider’s practice walls to inform payers and other organizations about their population’s well-being. A medical coder’s part in this effort is to capture and report SDOH codes correctly so providers, health plans, the government, and other entities can use this data to fund and manage populations for better health outcomes.
Data Behind the Claim
In 2017, Haynes-Maslow and Leone published a study evaluating the relationship between access to food and diabetes in the United States. The study found that the prevalence of diabetes in high-poverty counties is higher than in low-poverty counties. Another finding was that the prevalence of diabetes in counties (mostly low-poverty communities) with access to full-service restaurants and farmer’s markets is lower. On the other hand, in communities limited to fast-food restaurants and convenience stores, the prevalence of diabetes is much higher.
More studies have been published with similar conclusions where socioeconomic factors affect patients’ management and disease progression. These factors are driving the healthcare system to incorporate new strategies to identify social information in patient encounters and incorporate a holistic approach that not only takes care of diseases but SDOH, as well.
Collecting information from patients that allows you to assess whether they are encountering SDOH is not an easy task. For one thing, patients are not always forthcoming with such details. Your organization will need to devise a plan. SDOH plans may include activities such as:
- Assess and improve office practice workflows to implement SDOH initiatives without increasing staff burden.
- Evaluate and update clinical documentation templates where SDOH can be captured. Select an SDOH screening tool as a resource.
- Train providers, front desk staff, medical assistants, and other personnel on the importance of capturing and addressing patients’ SDOH.
- Develop a plan to use Z code data to:
- Enhance patient care and improve care coordination and referrals;
- Support quality measurement;
- Identify community/population needs and support planning and implementation of related interventions; and
- Monitor SDOH intervention effectiveness.
Cross-walking SDOH to ICD-10-CM
Healthy People groups SDOH into five categories:
1. Healthcare Access and Quality
This category addresses the relationship between people’s access to and understanding health services and their own health. SDOH include access to healthcare, health insurance coverage, and health literacy.
Most of these SDOH can be found in ICD-10-CM categories Z55 and Z56, and code Z91.120.
2. Education Access and Quality
This category incorporates the relationship between education and health. Key SDOH include obtaining a high school diploma or higher education, childhood education, and development.
See categories Z55 and Z62.
3. Social and Community Context
This category considers the context within which people live, learn, work, and play. Examples are cohesion within a community, civic participation, discrimination, issues in the workplace, and incarceration.
See categories Z57, Z60, and from Z60 to Z65.
4. Economic Stability
This category describes the connection between people’s financial resources, such as income and cost of living, and their health. Examples include poverty, employment, food security, and housing stability.
See categories Z56 and Z59.
5. Neighborhood and Built Environment
This category addresses the link between where a person lives — housing, neighborhood, and the environment — and their health. Examples include quality of housing, access to transportation, accessibility to healthy foods, water quality, and neighborhood violence.
See categories Z58 and Z59.
SDOH Clinical Documentation and Reporting Guidelines
According to the ICD-10-CM Official Guidelines for Coding and Reporting, SDOH should be reported when the information is documented. This documentation does not need to be established by a physician or other provider type since this data represents social information rather than medical diagnoses. In other words, front desk personnel can collect this information while checking in patients.
Medical coders should report SDOH if they are:
- Documented by medical assistants, social workers, case managers, or nurses, and the SDOH information is included in the official medical record; or
- SDOH are documented by the patient and this self-reported information is signed off on and incorporated into the medical record by either a clinician or the patient’s provider.
The government and other health organizations are providing guidance in collecting and addressing SDOH in the healthcare community. CDC has created an educational hub for providers to reference (see Resources for website).
There are many factors that can influence a patient’s health status and their contact with health services. Such social determinants of health (SDOH) are reportable with ICD-10-CM “Z” codes when either documented in the medical record, collected by other clinical or non-clinical staff, or self-reported. Incorporating a questionnaire that patients can complete in the waiting room or online prior to their visit allows providers to learn of and address any external factors that may impede their patients’ health outcomes. There are an infinite number of SDOH questionnaires available online or you may concoct your own. The following is a coding crosswalk to some of the more common questions found in SDOH questionnaires and the applicable Z codes (not an inclusive list).
Haynes-Maslow, L., Leone, L.A. Examining the relationship between the food environment and adult diabetes prevalence by county economic and racial composition: an ecological study. BMC Public Health, 17, 648 (2017).
CMS, Using Z Codes
- Coding SDOH Takes Practice - May 2, 2022
- Resolve Initial vs. Subsequent Encounter Misconceptions - December 1, 2021
- Is MEAT Satisfying Your RAF Hunger? - May 1, 2021