Social determinants of Health question

[Miko24]

He never got the prescription because it was too expensive and not covered by insurance. Would this fall under the social determinants of Health and if so would I be looking at Z95.7?

thank you

 

[lgardner]

This could fall under SDOH, as long as the provider documents how this is affecting the patient's health. I know this seems like an obvious example, but it has to be documented by the provider.

Per ICD-10-CM 2023 Guidelines (pages 103/104):

Social Determinants of Health
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. For example, a patient who lives alone may suffer an acute injury temporarily impacting their ability to perform routine activities of daily living.
When documented as such, this would support assignment of code Z60.2, Problems related to living alone. However, merely living alone, without documentation of a risk or unmet need for assistance at home, would not support assignment of code Z60.2. Documentation by a clinician (or patient-reported information that is signed off by a clinician) that the patient expressed concerns with access and availability of food would support assignment of code Z59.41, Food insecurity. Similarly, medical record documentation indicating the patient is homeless would support assignment of a code from subcategory Z59.0-, Homelessness

I think that Z59.7 could be an appropriate code. I would also consider Z59.6, Z59.86 or Z59.89.

ALSO, if the provider who documented that the pt didn't fill the Rx for financial reasons, I would code Z91.120 - Patient's intentional underdosing of medication regimen due to financial hardship [code first underdosing of medication (T36 - T50) iwht fifth or sixth character 6], if appropriate.