eHI Explains ICD-10-CM Coding for Social Determinants of Health

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eHI Explains ICD-10-CM Coding for Social Determinants of Health

October 9, 2019

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  • What is an ICD-10-CM code?
    International Classification of Diseases, Tenth Revision, Clinical Modification coding, known as ICD-10-CM coding, is a system used by clinicians to classify and record all diagnoses and symptoms for care within the United States. Codes are based on the International Classification of Diseases, which is published by the World Health Organization (WHO), using unique alphanumeric codes to identify known diseases and other health problems. ICD-10-CM codes provide a level of detail that is necessary for storing and retrieving diagnostic information, compiling national mortality and morbidity statistics, and processing health insurance claims.


  • What is an ICD-10-CM Z code for Social Determinants of Health (SDOH)?
    ICD-10-CM codes include a category called Z codes, which are used to describe experiences, circumstances, or problems that affect patient health, but are not considered a specific disease or injury. Z codes identify patients facing socioeconomic and psychosocial circumstances that may influence their health status and contact with health services. Currently, codes included in categories Z55-Z65 document patients’ SDOH in a standardized manner.


  • How does standardizing the capture of SDOH data codes benefit population health?
    Traditionally, data recorded during a patient visit directly relates to a patient’s health but does not incorporate outside factors that can impact well-being. SDOH data captures information at a level traditional health data sources cannot, and ICD-10-CM Z codes can record this information, giving deeper insights into factors impacting health, such as employment, food insecurity, and housing. Standardizing SDOH would assist in identifying, documenting, and tracking additional markers of health, beyond the physical, and would permit clinicians, hospitals, and health plans to share the information through medical records and insurance claims data.


  • Are there guidelines for using ICD-10-CM codes for SDOH?
    ICD-10-CM diagnosis codes have been adopted under the Health Insurance Portability and Accountability Act (HIPAA) for all healthcare settings. Guidelines for Z codes are included in the Centers for Medicare & Medicaid Services (CMS) ICD-10-CM Official Guidelines for Coding and Reporting for FY 2020.


  • Why should providers, non-physician healthcare providers, and coders use ICD-10-CM Z codes for SDOH?
    Utilizing Z codes for SDOH enables hospitals and health systems to better track patient needs and identify solutions to improve the health of their communities. The extraction of SDOH data from the Electronic Health Record (EHR) for clinical, operational, and research purposes can facilitate tracking, identification, and referrals to social and governmental services. Rather than a new system or new tool to capture SDOH, leveraging existing ICD-10-CM codes offers an opportunity to expand on the existing system. This practical application brings SDOH into a clinician’s workflow and becomes a part of the patient’s electronic medical record and claims history.


  • What are the limitations of ICD-10-CM Z codes for SDOH?
    Currently, Z codes for SDOH capture some, but not all, domains of SDOH. Stakeholder groups have requested that the ICD-10 Coordination and Maintenance Committee expand the codes to represent more granular information that would inform more precise, effective, and efficient social interventions, such as “barrier situations” which prevent consumers from obtaining medications and routine and preventive care. Although coding for SDOH is not mandated, when there is documentation of SDOH in the patient’s notes, it is still possible to use Z codes in the same manner that medical coding is done. Coding professionals may not know to scan for SDOH or may be hesitant to use the codes. Additionally, if a code has not been developed for a specific SDOH issue, the issue will not be coded and will not be included in the patient’s overall plan of care, nor as part of the claim submission process, unless it is recorded as narrative text.


  • Are coding professionals allowed to use non-physician documentation to support ICD-10-CM coding for societal and environmental conditions?
    Yes, coding professionals at hospitals and health systems can report these codes based on documentation by all clinicians involved in the care of patients, such as case managers, discharge planners, social workers and nurses. In early 2018, the American Hospital Association’s (AHA) Coding Clinic published guidance that allows the reporting of SDOH ICD-10 codes based on non-physician documentation. The ICD-10-CM Cooperating Parties approved the advice, with the change effective February 2018.


  • Where can I find more resources and initiatives around SDOH data and ICD-10-CM Coding?