A recent medical research publication titled: International Classification of Diseases, Tenth Revision, Clinical Modification social determinants of health codes are poorly used in electronic health records; describes the underreporting of the Social Determinants of Health (SDOH) via ICD-10-CM (International Classification of Disease, Tenth Revision, Clinical Modification) codes.  The SDOH ICD-10-CM codes are found in the Chapter 21, Factors influencing health status and contact with health services, of the classification in the range of Z55 – Z65, which is used in the United States primarily for medical record/encounter data and claim submission, as well as other analysis and research.

Social determinants of health are conditions in the places where people live, learn, work, and play that affect a wide range of health and quality-of life-risks and outcomes, often they are socioeconomic.  SDOH codes describe conditions such as poverty, hunger, homelessness, abuse, neglect, employment, status, etc. The research study examined the utilization rate of the ICD-10-CM SDOH Z codes, between the years 2015-2018, using data from a large network of EHRs and found a low rate of SDOH, 2.03%.

Go to the following site to read over the study: https://journal.lww.com/md-journal/fulltext/2020/12240/international_classification_of_diseases,_tenth.50.aspx

The ICD-10-CM Official Guidelines for Coding and Reporting has published guidance for Health Information Management (HIM) and Coding professionals, indicating that all clinicians, not just the physicians, involved in the care of a patient can document SDOH using these Z codes. In addition, ICD-10-CM guidance states that SODH information obtained from the patient (self-reported) and incorporated into the medical record can be utilized for clinical coding.

Keep in mind that SDOH provide real specific information and data about the whole patient/person. Capturing SDOH assists with having data that goes beyond the billing claim data and provides a lens into the social and economic situation and condition of that individual patient. The SDOH data is extremely valuable to population health management and disease prevention.

The Centers for Disease Control and Prevention (CDC) has a dedicated site on SDOH, this too strongly encourages the collection of this data. The CDC believes that SDOH will help with chronic disease indicators, disease surveillance, addressing health disparities, compare health in different types of disability and public health disease tracking. Visit: www.cdc.gov/socialdeterminants/index.htm

It is clear that we need to and want to be able to improve health and healthcare throughout America. There continues to be a drive to obtaining health equality and the SDOH can provide a powerful insight to help providers, the  government, researchers and society as a whole.

So, answer this question . . .  What is your hospital or practice SDOH ICD-10-CM capture percentage? In order to answer this, you’ll need to plan and conduct a thorough documentation and coding audit/review.  One area for a hospital to start with is the Emergency Room encounters. DO NOT waste any time, reach out to RMC to help today with your SDOH audit(s).

By: Gloryanne Bryant, RHIA, CDIP, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

Contact Reimbursement Management Consultants (RMC) for assistance with medical coding support, auditing, compliance, and CDI. RMC is a Woman-owned, US-based company which specializes in a variety of medical coding compliance consulting services. Click here for more information!