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The health information management (HIM) world has been buzzing recently with discussion of social determinants of health and coded data. What does this mean for coders and the HIM field?
What Are Social Determinants of Health?
Social determinants of health (SDOH) are the economic and social conditions in which people are born, live, grow, work and age. They may impact a wide range of health and quality of life risks and outcomes for patients. SDOH can include a history of physical abuse, homelessness, economic circumstances affecting healthcare, social exclusion and rejection, and problems related to education and literacy. Although these types of determinants may be documented within the medical record, they may not always be coded.
They are best captured by the ICD-10-CM codes within Chapter 21: Factors influencing health status and contact with health services (Z00-Z99). Below are some of the broad categories of SDOH codes:
- Persons with potential health hazards related to socioeconomic and psychosocial circumstances (Z55-Z65)
- Z55, Problems related to education and literacy
- Z56, Problems related to employment and unemployment
- Z57, Occupational exposure to risk factors
- 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
- Z64, Problems related to certain psychosocial circumstances
- Z65, Problems related to other psychosocial circumstances
How Are SDOH Codes Used?
The data collected from claims with reported SDOH codes is being used by the Centers for Medicare and Medicaid Services (CMS) to analyze data and health trends. For example, of the 33.7 million total Medicare fee-for-service (FFS) beneficiaries in 2017, approximately 1.4 percent had claims with Z codes. The five most utilized Z codes from this article were:
- 0, Homelessness
- 2, Problems related to living alone
- 4, Disappearance and death of family member
- 8, Other specified problems related to psychosocial circumstances, and
- 0, Problems in relationship with spouse or partner
These conditions have been shown to negatively affect such outcomes as hospital readmission rates, length of stay, and use of post-acute care services. A 2014 National Academies of Medicine (NAM) report suggested that the collection of SDOH data in an electronic health record (EHR) is necessary to empower providers to address health disparities and to support further research on the effects of SDOH.
For example, of the 467,136 Medicare FFS beneficiaries in 2017 with Z code claims, 334,373 (72 percent) had hypertension and 248,726 (53 percent) had depression. You can see where the use of the SDOH data can be helpful in various ways.
The data source for the study in Medicare claims came from the CMS Chronic Condition Data Warehouse (www.ccwdata.org).
What Is a Coder to Do?
Coders are not new to Z codes and have frequently assigned these for things such as personal and family histories, statuses, and long term use of drugs—among other things.
Coders should become familiar with Z codes that include SDOH if they have not already. Coders usually put little emphasis and time on finding SDOH in the EHR and coding them.
This is changing, however, and coders should begin to identify the documented SDOH and code them in ICD-10-CM when documented and codes are available. They do not necessarily have to be documented by the actual physician or provider.
According to AHA Coding Clinic, 1Q2018 page 18, categories Z55-Z65 are acceptable to report based on information documented by other clinicians involved in the care of the patient. That means that coders can code SDOH from nursing and other documentation.
The coder should check with their facility to see if there are specific areas in the EHR where this is documented if it is not evident. Coders are going to be seeing the documentation of SDOH increasing. I encourage all coders to read the article in the link below under “Additional Reading” so they can see the breadth of the use of this data.
The use of coded data is becoming more and more robust and required in an ever-changing healthcare world.
- Download Health Information Associates’ SDOH infographic
- AHA ICD-10 CM Coding for SDOH
- CDC research on SDOH
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Pat Maccariella‑Hafey,RHIA, CDIP, CCS, CCS‑P, CIRCC, AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador, (firstname.lastname@example.org) is executive director of education at Health Information Associates, a recognized leader in coding support, review, and education services.
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