Revenue Cycle Insider

Capture the complexity of cancer care by painting the full patient picture.

According to the U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion, social determinants of health (SDOH) are “conditions in the environments where 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.”

SDOH are no longer considered background noise in clinical care, especially in oncology. From housing insecurity to transportation barriers, these variables increasingly shape how cancer is detected, treated, and managed. And with this shift, medical coding in oncology is also transforming to reflect the true scope of patient care.

Here’s how.

Understanding SDOH in Oncology

Altogether, there are five domains of SDOH:

1. Economic stability
2. Education access and quality
3. Healthcare access and quality
4. Neighborhood and built environment
5. Social and community context

In oncology, these factors deeply affect a patient’s ability to access screening, adhere to treatment, and recover successfully. They especially affect patients in underserved communities, who often encounter obstacles that result in delayed diagnoses, limited treatment options, and higher mortality rates.

Coding systems have traditionally focused on clinical encounters and diagnoses. But a growing emphasis on whole-person centered care has created a shift in medical coding. Healthcare providers now aim to document and address the social complexities that impact cancer care and medical coders now have the ability to capture these complexities with ICD-10-CM codes.

Familiarize Yourself With the SDOH Z Codes

The introduction and expansion of ICD-10-CM codes Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) allow healthcare providers and coders to document SDOH such as housing and economic problems (Z59), employment and unemployment issues (Z56), and education and literacy barriers (Z55).

The codes break down as follows:

These codes, when used accurately, help build a more comprehensive patient record, highlighting social challenges that may directly interfere with treatment adherence or outcomes.

In oncology, the inclusion of these codes can flag high-risk patients for additional support services like care management, financial counseling, or community-based programs, transforming how care teams plan and prioritize interventions.

Know These Payment Models and New Services

Recent healthcare policies have reinforced the value of addressing SDOH in cancer care. In 2024, the Centers for Medicare & Medicaid Services (CMS) introduced billable codes for services like principal illness navigation (PIN) and community health integration (CHI). These services involve trained professionals, such as nurse navigators, who assist oncology patients in navigating barriers like food insecurity, transportation needs, and psychosocial stressors.

In addition, documentation of SDOH factors may make the difference between evaluation and management (E/M) visit levels, as addressing SDOH is included in the E/M medical decision making (MDM) table of risk at the moderate level.

This has added another layer to coding in oncology, making SDOH not just clinically relevant, but also financially actionable. Accurate SDOH coding now plays a vital role in ensuring that these services are properly documented and billed.

Rise to the Documentation Challenge

Despite growing awareness, capturing SDOH data remains challenging. Providers may hesitate to ask sensitive questions, and patients may be reluctant to disclose personal information. However, SDOH can be self-reported by patients and incorporated into the medical record by any clinical staff, not just physicians. This flexibility helps ensure these factors are captured even if they arise during intake or follow-up calls.

So, training clinical staff to screen for SDOH, and educating coders to recognize the cues in provider documentation, are vital next steps in closing this gap. This also means educating providers to document a patient’s SDOH comprehensively, as incomplete provider notes often result in missed coding opportunities.

For example: A patient with cancer misses chemotherapy appointments due to unreliable transportation. The provider must adjust the treatment plan, increasing the complexity of care. Documenting this SDOH factor supports a higher E/M level and ensures appropriate reimbursement for the added care burden.

Know Why SDOH Focus Matters

As value-based care becomes the norm, accurately reflecting all factors making up a patient’s life is more important than ever. Integrating SDOH into medical documentation and medical coding helps identify population-level disparities, informs public health strategies, and ensures that resources are directed where they’re needed most. In oncology, where patients often endure complex and prolonged treatment journeys, capturing SDOH through coding is especially important.

By intertwining social realities into the basic fabric of cancer care, oncology coding is becoming not only more accurate but also more compassionate. In the fight against cancer, understanding the human context may sometimes prove as vital as understanding the cancer itself.

Nikki Taylor, MSHCI, COC, CPC, CPCO, CPMA, CRC, AAPC Approved Instructor, McKesson