impact of coding for social determinants of health

Impact of Coding forSocial Determinants of Health

Stacey LaCottiSenior Associate, Content

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Stuart Newsome, CPCOVice President Strategic Partnerships

Stacey LaCottiSenior Associate, Content Marketing & Sales

Enablement30+ years in healthcare | CPCO Industry ExpertProvided 50+ education sessions | Conference speaker | Manages Alpha II’s largest clients

20+ years in Healthcare IT | Solutions Expert Provided 50+ education sessions

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Audience Poll


What are social determinants of health (SDoH)?


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What are social determinants of health (SDoH)?

• 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

• Socioeconomic and psychosocial factors that impact a person’s health and well-being

• Food• Housing• Transportation• Education• Violence• Social support• Health behaviors• Employment

80%All health outcomes

driven by SDoH


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Why are these factors important?

• Part of an overall effort to improve health of patients and communities

• Contributes to move toward value-based care

• Aggregates data for patient populations to allow focus on a community-wide treatment strategy

• Opens access to resources that enhance quality of life and can have a significant influence on population health outcomes

• Contributes toward medical professionals’ ethical duty to provide complete care that addresses the overall health of the patient


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Healthy People 2020

• Launched in 2010 by Office of Disease Prevention and Health Promotion (ODPHP)

• Began as a 10-year agenda for improving health in the U.S.• Identify nationwide health improvement priorities• Increase awareness and understanding of determinants of health , disease, and disability

and opportunities for progress • Provide measurable objectives and goals applicable at the national, state, and local levels • Engage multiple sectors to take actions to strengthen policies and improve practices that

are evidence driven• Identify critical research, evaluation, and data collection needs

• Extended to Healthy People 2030 to continue initiative with new objectives


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SDoH Categories Defined by Healthy People 2020 (2030)

https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health

Economic Stability

• Employment• Food Insecurity• Housing Instability• Poverty

Healthcare Access and Quality

• Access to Health Care

• Access to Primary Care

• Health Literacy

Education Access and Quality

• Early Childhood Education and Development

• Enrollment in Higher Education

• High School Graduation

• Language and Literacy

Social and Community Context

• Civic Participation• Discrimination• Incarceration• Social Cohesion

Neighborhood and Built Environment

• Access to Foods that Support Healthy Eating Patterns

• Crime and Violence• Environmental

Conditions• Quality of Housing

https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health


Collecting patient data for social determinants of health


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How to collect SDoH data• Any member of the patient’s care team can collect SDoH data

• Providers• Social workers• Community health workers• Case managers• Patient navigators• Nurses

• Can be collected a several steps in the care process• Health risk assessment• Screening tool• Person-to-provider interaction• Individual self-reporting

• Patient self-reported documentation may be used to assign codes for SDoH as long as the patient’s self-reported information is signed-off by and incorporated into the health record by a clinician or provider

https://www.cms.gov/files/document/2021-coding-guidelines-updated-12162020.pdf I.B.14 (16)

https://www.cms.gov/files/document/2021-coding-guidelines-updated-12162020.pdf%20I.B.14


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Road blocks for collecting data• Lack of standardized screening tool

• Accountable Health Communities Model (next slide)• CDC tools and resources• Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)• HealthBegins Upstream Risks Screening Tool & Guide

• Lack of data collection and storage points in EHR• Company policy doesn’t define process for data collection and usage• Staff time is already limited

• Don’t have time to provide assessment, analyze answers, update records• Not sure what services exist for patient referral

• Patients don’t want to provide answers to such personal questions

https://www.cdc.gov/socialdeterminants/tools/index.htm

https://www.nachc.org/research-and-data/prapare/toolkit/

https://www.aamc.org/system/files/c/2/442878-chahandout1.pdf


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CMS Accountable Health Communities Model

• Addresses critical gaps between clinical care and community services in the current health care delivery system

• Identifies and addresses health-related social needs of Medicare and Medicaid beneficiaries’ through

• Screening• Referral• Community navigation services

• Developed screening tools and guides• Accountable Health Communities Health-Related Social Needs Screening

Tool (PDF)

https://innovation.cms.gov/innovation-models/ahcm

https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf

https://innovation.cms.gov/innovation-models/ahcm


How to code social determinants of health


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SDoH ICD-10-CM Diagnosis Codes• Z codes are a subset of ICD-10-CM

diagnosis codes that represent factors influencing health status and contact with health services that may be recorded as diagnoses

• SDoH diagnosis code range is Z55-Z65and represent people with potential health hazards related to socioeconomic and psychosocial circumstances

• Should never be billed as primary diagnosis on a claim


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SDoH ICD-10-CM Diagnosis Codes

Z55 – Problems related to education and literacy• Z55.0: Illiteracy and low-level literacy• Z55.1: Schooling unavailable and unattainable• Z55.2: Failed school examinations• Z55.3: Underachievement in school• Z55.4: Educational maladjustment and discord with teachers and

classmates• Z55.8: Other problems related to education and literacy• Z55.9: Problems related to education and literacy, unspecified


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Z56 – Problems related to employment and unemployment• Z56.0: Unemployment, unspecified• Z56.1: Change of job• Z56.2: Threat of job loss• Z56.3: Stressful work schedule• Z56.4: Discord with boss and workmates• Z56.5: Uncongenial work environment• Z56.6: Other physical and mental strain related to work• Z56.8: Other problems related to employment (not billable)

• Z56.81: Sexual harassment on the job• Z56.82: Military deployment status• Z56.89: Other problems related to employment

• Z56.9: Unspecified problems related to employment


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Z57 – Occupational exposure to risk factors• Z57.0: Occupational exposure to noise• Z57.1: Occupational exposure to radiation• Z57.2: Occupational exposure to dust• Z57.3: Occupational exposure to other air contaminants (not billable)

• Z57.31: Occupational exposure to environmental tobacco smoke• Z57.39: Occupational exposure to other air contaminants

• Z57.4: Occupational exposure to toxic agents in agriculture• Z57.5: Occupational exposure to toxic agents in other industries• Z57.6: Occupational exposure to extreme temperature• Z57.7: Occupational exposure to vibration• Z57.8: Occupational exposure to other risk factors• Z57.9: Occupational exposure to unspecified risk factor


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Z59 – Problems related to housing and economic circumstances• Z59.0: Homelessness• Z59.1: Inadequate housing• Z59.2: Discord with neighbors, lodgers and landlord• Z59.3: Problems related to living in residential institution• Z59.4: Lack of adequate food and safe drinking water• Z59.5: Extreme poverty• Z59.6: Low income• Z59.7: Insufficient social insurance and welfare support• Z59.8: Other problems related to housing and economic circumstances• Z59.9: Problem related to housing and economic circumstances, unspecified


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Z60 – Problems related to social environment• Z60.0: Problems of adjustment to life-cycle transitions• Z60.2: Problems related to living alone• Z60.3: Acculturation difficulty• Z60.4: Social exclusion and rejection• Z60.5: Target of (perceived) adverse discrimination and persecution• Z60.8: Other problems related to social environment• Z60.9: Problem related to social environment, unspecified


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• Z62 – Problems related to upbringing• Z62.0: Inadequate parental supervision and control• Z62.1: Parental overprotection• Z62.2: Upbringing away from parents (not billable)

• Z62.21: Child in welfare custody• Z62.22: Institutional upbringing• Z62.29: Other upbringing away from parents

• Z62.3: Hostility towards and scapegoating of child• Z62.6: Inappropriate (excessive) parental pressure


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SDoH ICD-10-CM Diagnosis Codes• Z62 – Problems related to upbringing (cont’d)

• Z62.8: Other specified problems related to upbringing (not billable)• Z62.81: Personal history of abuse in childhood (not billable)

• Z62.810: Personal history of physical and sexual abuse in childhood• Z62.811: Personal history of psychological abuse in childhood• Z62.812: Personal history of neglect in childhood• Z62.813: Personal history of forced labor or sexual exploitation in childhood• Z62.819: Personal history of unspecified abuse in childhood

• Z62.82: Parent-child conflict (not billable)• Z62.820: Parent-biological child conflict• Z62.821: Parent-adopted child conflict• Z62.822: Parent-foster child conflict

• Z62.89: Other specified problems related to upbringing (not billable)• Z62.890: Parent-child estrangement NEC• Z62.891: Sibling rivalry• Z62.898: Other specified problems related to upbringing

• Z62.9: Problem related to upbringing, unspecified


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SDoH ICD-10-CM Diagnosis CodesZ63 – Other problems related to primary support group, including family circumstances

• Z63.0: Problems in relationship with spouse or partner• Z63.1: Problems in relationship with in-laws• Z63.3: Absence of family member (not billable)

• Z63.31: Due to military deployment• Z63.32: Other absence of family member

• Z63.4: Disappearance and death of family member• Z63.5: Disruption of family by separation and divorce• Z63.6: Dependent relative needing care at home• Z63.7: Other stressful life events affecting family and household (not billable)

• Z63.71: Stress on family due to return of family member from military deployment• Z63.72: Alcoholism and drug addiction in family• Z63.79: Other stressful life events affecting family and household

• Z63.8: Other specified problems related to primary support group• Z63.9: Problem related to primary support group, unspecified


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SDoH ICD-10-CM Diagnosis CodesZ64 – Problems related to certain psychosocial circumstances

• Z64.0: Problems related to unwanted pregnancy• Z64.1: Problems related to multiparity• Z64.4: Discord with counselors


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SDoH ICD-10-CM Diagnosis CodesZ65 – Problems related to other psychosocial circumstances

• Z65.0: Conviction in civil and criminal proceedings without imprisonment• Z65.1: Imprisonment and other incarceration• Z65.2: Problems related to release from prison• Z65.3: Problems related to other legal circumstances• Z65.4: Victim of crime and terrorism• Z65.5: Exposure to disaster, war and other hostilities• Z65.8: Other specified problems related to psychosocial circumstances• Z65.9: Problem related to unspecified psychosocial circumstances


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Considering SDoH in E&M Medical Decision-Making

• 2021 Office/Outpatient E&M updates included a consideration for SDoH

• Elements of Medical Decision Making chart

• Moderate level codes (99204 and 99214) in the “Risk of Complications an/or Morbidity or Mortality of Patient Management” column

• Diagnosis or treatment significantly limited by social determinants of health

• Remember – just because there is a Z code present in the medical record, it doesn’t mean it is automatically a moderate risk!

• Must meet 2 out of three elements to code that level


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How can we get started?


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Suggestions for Implementing SDoH Protocols

Health Care Administrators• Educate key stakeholders on importance of screening, documenting and coding data on

patients’ social needs and provide training to support data collection• Select an SDOH screening tool• Identify workflows that minimize staff burden• Invest in EHRs that facilitate data collection and coding• Decide what Z code data to use and monitor

• SDoH data can be added to key reports for executive leadership and Boards of Directors to inform value-based care opportunities

• Findings can be shared with social service organizations, providers, health plans, and consumer/patient advisory boards to identify unmet needs

• A Disparities Impact Statement can be used to identify opportunities for advancing health equity

https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Disparities-Impact-Statement-508-rev102018.pdf

https://www.cms.gov/About-CMS/Agency-Information/OMH/Downloads/Disparities-Impact-Statement-508-rev102018.pdf


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Health Care Team

• Follow best practices for collecting SDoH data in a sensitive and HIPAA-compliant manner

• Consistently document standardized SDoH data in the EHR• SDoH data may be documented in the problem or diagnosis list, patient or client history,

or provider notes

• Identify individuals’ social risk factors and unmet need to drive patients’ health care and services, follow-up, and discharge planning

• Refer individuals to social service organizations and appropriate support services through local, state, and national resources

• Track referrals between providers and social service organizations


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Coders• Follow ICD-10-CM coding guidelines• Assign SDoH Z codes based on self-reported data and/or information

documented in an individual's health care record by any member of the care team

• Coding team managers should review codes for consistency and quality

• Assign all relevant SDoH Z codes to support quality improvement initiatives

• Stay current on revisions and additions to SDoH diagnosis codes and guidelines• Use coding and billing systems to assist with standardized coding practices


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https://www.healthypeople.gov/2020/leading-health-indicators



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impact of coding for social determinants of health

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