Ophthalmology and Optometry Coding Alert

Review answers to the five most frequently asked questions about SDoH coding.

Over the last few years, capturing non-medical factors that influence health outcomes in the patient’s medical record has become easier thanks to the steady increase in the number of diagnosis codes available to document these conditions, known as social determinants of health (SDoH). The 2023 ICD-10-CM code set further boosts your options, enabling you to provide a holistic view of a patient’s overall health.

These changes, effective Oct. 1, 2023, have led you to ask a number of questions about SDoH coding, which we’ve assembled in this handy FAQ for easy reference.

Q: What Are Social Determinants of Health?

Medical care accounts for only a small percentage of health outcomes. The remaining majority may tie directly to environmental and socioeconomic circumstances and individual behavior. All of these things factor into a patient’s overall picture of health or lack thereof.

SDoH are the economic and social conditions in which people are born, live, grow, learn, work, and age. They may impact a wide range of health and quality of life risks and outcomes for patients. They include factors such as:

• Availability of resources (i.e., safe housing, transportation, local food stores)
• Access to educational and job opportunities
• Circumstances affecting access to healthcare
• Socioeconomic conditions
• Exposure to crime, violence, and social disorder
• Social norms and attitudes (i.e., discrimination, racism, criminal justice climate)

Each of these variables can have a significant impact on an individual’s health. Although these types of determinants may be documented within the medical record, they have not always been coded by coders. Now more than ever, it is important that you report them.

Q: What’s a Coder to Do?

Start by recognizing the importance of reporting the Z55-Z65 codes. While it’s not mandatory that you report these codes, there are plenty of 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.

More, “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 form a comprehensive picture of the social context your practice’s patients find themselves.

Q: How Do I Report SDoH?

You’ll find all the codes you need to report SDoH in the Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances) group of codes.

Expert coding tip: Before using one of these codes, familiarize yourself with the main ICD-10-CM guideline that governs their use. Per I.B.14, codes in categories Z55-Z65 “should only be reported as secondary diagnoses.” Additionally, Z55-Z65 are some of the only diagnostic codes 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,” the guidelines go on to elaborate.

Q: What’s New in SDoH Coding for 2023?

The first significant revision of note is the expansion to the Z59.8- (Other problems related to housing and economic circumstances) code set, which will allow you to capture ways in which a patient’s health is affected by their social circumstances in much greater detail.

This expansion “now allows for further specificity when coding for other problems related to housing and economic circumstances,” notes Amy Pritchett, CCS, CPC-I, CPMA, CDEO, CASCC, CANPC, CRC, CDEC, CMPM, C-AHI, senior consultant at Pinnacle Enterprise Risk Consulting Services LLC, in Centennial, Colorado.

“Prior to the expansion of Z59.8, everything rolled into the ‘other’ code. But the addition of a fifth digit — 2, 6, 7 — allows you to document transportation insecurity, financial insecurity, and material hardship,” Pritchett adds.

The three new codes and their inclusion terms are:

• Z59.82 (Transportation insecurity): Includes excessive transportation time along with inaccessible, inadequate, lack of, unaffordable, unreliable, and unsafe transportation
• Z59.86 (Financial insecurity): Includes bankruptcy, burdensome debt, economic strain, financial strain, money problems, running out of money, and being unable to make ends meet
• Z59.87 (Material hardship): Includes material deprivation and inability to obtain adequate childcare, adequate clothing, adequate utilities, and basic needs

Additionally, ICD-10-CM 2023 contains new Excludes2 notes stating you can code extreme poverty (Z59.5), low income (Z59.6) or material hardship NEC (Z59.87) with Z59.86 and extreme poverty (Z59.5), financial insecurity, not elsewhere classified (Z59.86) and low income (Z59.6) with Z59.87.

Q: Are There Any Changes to the SDoH Guidelines?

Yes. ICD-10-CM 2023 has also expanded guideline I.C.21.c.17 to help you use the codes effectively. This change is significant because it removes an apparent contradiction within ICD-10-CM guidelines and between ICD-10 and CPT^® guidelines, according to Wolf.

“ICD-10 guideline IV.J. states that we should ‘Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care treatment or management’” Wolf notes. Similarly, the recent revisions to the office/outpatient evaluation and management (E/M) guidelines include SDoH as a moderate risk level of medical decision making (MDM), but only when “the treatment is ‘significantly limited’ by SDoH in order for SDoH to be considered,” Wolf adds.

The guideline expansion will help you determine the number and relevance of codes you should use in a patient’s record, telling you to assign SDoH codes “when the documentation specifies that the patient has an associated problem or risk factor.” To clarify, the guideline provides the example that “not every individual living alone would be assigned code Z60.2, Problems related to living alone.” You would only use that code if the patient’s solitary life limited their ability to take care of themselves.