Resource on ICD-10-CM Coding for Social Determinants of Health

Introduction

Hospitals and health systems are working to address their patients’ social needs and the broader social determinants of health in the communities they serve. This includes societal and environmental conditions such as food, housing, transportation, education, violence, social support, health behaviors and employment.

Robust data related to patients’ social needs is critical to hospitals’ efforts to improve the health of their patients and communities. And, employing a standardized approach to screening for, documenting and coding social needs will enable hospitals to:

• Track the social needs that impact their patients, allowing for personalized care that addresses patients medical and social needs;
• Aggregate data across patients to determine how to focus a social determinants strategy; and
• Identify population health trends and guide community partnerships.

One tool available to hospitals to capture data on the social needs of their patient population is the ICD-10-CM codes included in categories Z55-Z65 (“Z codes”), which identify non-medical factors that may influence a patient’s health status. Existing Z codes identify issues related to a patient’s socioeconomic situation, including education and literacy, employment, housing, lack of adequate food or water or occupational exposure to risk factors like dust, radiation, or toxic agents.

Despite the availability and utility of these ICD-10-CM codes, hospitals have not widely adopted the use of Z codes. Adoption has been limited due to a lack of clarity on who can document a patient’s social needs, absence of operational processes for documenting and coding social needs, and unfamiliarity with Z codes. In addition, coders may need encouragement and support from hospital leaders to collect these codes that were once perceived as a lower priority.

Updated Guidance

The AHA is working to increase utilization of Z codes. The AHA Coding Clinic has provided further clarification on the appropriate documentation and use of Z codes to enable hospitals to adopt their use into their processes.

Any clinician can document a patient’s social needs.

The initial ICD-10-CM Official Guidelines for Coding and Reporting indicated that coding professionals could only report codes that were supported by physician documentation. As a result, many hospitals were unable to report social needs because they are routinely documented by non-physician providers, such as case managers, discharge planners, social workers and nurses. In early 2018, the AHA Coding Clinic published advice clarifying that codes from categories Z55-Z65 can be assigned based on information documented by all clinicians involved in the care of the patient. That advice was approved by the ICD-10-CM Cooperating Parties and effective Feb. 18, 2018.

While this change promoted more widespread use of these Z codes, the ICD-10-CM Official Guidelines for Coding and Reporting did not include a definition for “clinician.” As a result, effective Oct 1, 2019, the AHA Coding Clinic published additional advice providing this definition for the purpose of documenting social (vs. medical) information. Here, “clinicians” can include anyone deemed to meet the requirements, set by regulation or internal hospital policy, to document in the patient’s official medical record. This means that in many cases coding professionals can utilize documentation of social needs from clinicians including, but not limited to, social workers, community health workers, case managers, nurses or other providers.

For example, Sharp Grossmont Hospital’s Care Transitions Intervention Program deploys a multidisciplinary care team to conduct comprehensive risk assessments that screen patients for clinical and social risks. That care team includes nurses, case managers and social workers. And Baylor Scott & White Health’s Community Advocate Program trains volunteers from the local colleges to conduct social needs screenings and connect patients with appropriate services and resources. In both of these examples, provided these individuals were deemed appropriate to document this information in the patient’s medical record, that documentation would support the use of a Z code.

Patient self-reported social needs.

Hospitals often utilize patient self-report tools to identify social needs. If the patient self-reported information is signed-off and incorporated into the medical record by a clinician, that information can support the use of a Z code by coding professionals. For example, IHA/Trinity Health developed a self-report screening tool in English, Spanish and Arabic that is integrated with the electronic health record, enabling the health system to track responses, refer patients to community resources and follow up after their visit. Because that information is incorporated into the electronic health record, that information can support the use of a Z code. This change also is effective Oct. 1, 2019.

Additional Information on Coding

For more information on coding guidelines, contact Nelly Leon-Chisen, RHIA, AHA director of coding and classification, at nleon@aha.org.