Pediatric Coding Alert

Screen often for environmental factors influencing patient health, experts say.

We are all aware of the way such things as activity levels, diet, and immunizations influence a child’s health. But there are other, less visible forces at work on a child’s wellbeing.

Such things are known as social determinants of health, or SDoH, and they play a significant role in shaping a child’s overall wellness. But what, exactly, are they? How do you report them? And why do you need to report them anyway?

Here is what you need to know about coding for these significant influences on pediatric health.

What Are 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).

How Do I Report SDoH?

You’ll find 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. Many of the key codes you might need for reporting pediatric SDoH can be found in the following:

• 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)

Coding alert: Before using one of the Z55-Z65 codes, be sure you become familiar with the main ICD-10 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 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 go on to elaborate.

Do I Have to Report SDoH?

While there may not be any legal mandates for reporting the Z55-Z65 codes, there are some very good reasons for doing so. In their current Bright Futures Guidelines, the American Academy of Pediatrics (AAP) “prioritizes SDoH at the very top of Health Supervision visits at every age, outlining the specific items that are most important at each stage of life,” notes Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC.

This is because SDoH influences health in very direct ways. As an example, consider that “for adolescents alone, poverty correlates with high rates of ‘infant mortality, developmental delays, asthma, ear infections, obesity, and child abuse and neglect,’ according to Bright Futures,” Blanchard notes. More, the AAP “makes recommendations for managing adult diseases by acknowledging their developmental nature as disorders that begin early in life,” Blanchard adds.

That is why, “when the patient’s SDoH status affects the care of the patient, we have been encouraging our pediatric clinicians to use these codes as secondary codes on encounters,” says JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis. “We stress that these status codes can better show the complexity of the patient population they serve,” Wolf adds.

How and When Should We Screen for SDoH?

AAP provides an exhaustive list of screening tools for a variety of SDoH at its Screening Time site (screeningtime.org/star-center/). As for when you should administer them, “in the Children’s Health Network, we recommend that our primary care practices assess for SDoH at every well child checkup,” advises Wolf.

What Else Should I Know About SDoH?

In this issue, and previous issues, of Pediatric Coding Alert, we have been preparing you for the significant changes in the way you will code office and outpatient evaluation and management (E/M) codes beginning Jan. 1, 2021, including the way you will determine medical decision making (MDM). The new table of MDM elements lists SDoH as an example of a moderate-level risk of complication/morbidity when it significantly limits a patient’s diagnosis or treatment (See www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf).

Coding caution: While this change is a positive development, as “it provides us with yet another good reason to assess and document the SDoH status of our patients, it sets up a possible contradiction between ICD-10 and CPT^® guidelines,” warns Wolf. That’s because “ICD-10 guideline IV.J. states that we should ‘Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.’ But with the new E/M Documentation Guidelines for MDM, the diagnosis or treatment must be ‘significantly limited’ by SDoH in order for SDoH to be considered,” Wolf notes.