Social Determinants of Health – Coding Considerations

While we are aware that some of the reporting requirements for Social Determinants of Health (SDoH) are currently fluid, we know that those factors play a role in patient compliance and outcomes.  Homelessness and housing insecurity, food insecurity and transportation insecurity are among the factors impacted. 

It is a good time to review some coding guidelines on SDOH code assignment.  First, and maybe most importantly, we have a guideline that is specific to the SDOH code set of Z55 – Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances. 

Guidance instructs “For social determinants of health classified to chapter 21, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses.” 

This means coders can assign those codes based on supporting documentation from nurses, social workers, case managers and others.  As always, the supporting documentation must be documented and incorporated in the patient’s health record.  

The patient can also self-report any SDOH conditions or factors.  Here also this self-reported information must be both signed off by a provider or clinician and incorporated into the patient’s record. 

Another important reminder on the assignment of SDOH conditions is that the documentation should identify an associated problem or risk factor influencing the patient’s health during the current encounter.  The guidelines use Z60.2, Problems related to living alone as an example. 

It notes a patient who lives alone who suffered an acute injury that has temporarily impacted their ability to perform their daily activities.  In this case Z60.2 would be assigned to identify this SDOH factor.  Guidelines caution coders that documentation that the patient lives alone, without any additional information identifying a need for assistance or an associated risk, would not justify the assignment of Z60.2. 

It is the identification of that problem as noted in the code description – Problems related to living alone – that supports the assignment. 

Finally, the guidelines instruct us that we should assign as many SDOH codes as are necessary to describe all social problems, conditions, or risk factors that are documented during that current episode of care.  Facility coding policies and procedures should include direction on SDOH code assignment to ensure the entire coding staff are coding these consistently. 

Often as coders we get so focused on those diagnosis and procedure codes that these factors as well as other Z codes are not given the same emphasis.  These SDOH factors play an important part in the compliance and outcome of the patient.  While the current reporting requirements for some SDOH conditions may be fluid, the issues impacting the patient are not.  Consistent documentation, code assignment and data sharing of these items can help ensure we are providing patients with the resources they need to take care of their health and improve patient care outcomes.