Social Determinants of Health

How Hospitals, EDs Effectively Code Social Determinants of Health

Hospitals and emergency departments need to properly code for social determinants of health to improve tracking and reimbursement.

In 2021, the Centers for Medicare & Medicaid Services (CMS) issued guidance to emphasize the importance of social, economic, and environmental factors that can affect the health outcomes of disadvantaged populations. Known collectively as social determinants of health (SDOH), they often have a more significant impact on the health outcomes of patients than the actual delivery of health services. These factors can include access to food and transportation, housing security, education, violence, social support, health behaviors, and employment status.

“Social determinants of health can also impact the complexity of patient care in an office, hospital, or emergency department setting,” explains Dr. Brault, President and CEO of Brault Practice Solutions. “For example, food insecurity, poverty, or homelessness can add significant risk and complexity when determining a diagnosis and treatment plan — even for common complaints such as chest pain, abdominal pain, and fever.”

Physicians have had the ability to document SDOH since ICD-10 was adopted in 2015, but this recent CMS guidance now adds greater awareness to the health impact of these conditions.

By tracking these population health trends, CMS hopes to reduce health disparities and reduce the overall cost of caring for our nation’s most vulnerable and high-risk populations. The federal agency also hopes to add more focus to federal and state policies, and influence hospital-level funding. On a larger scale, this data also rolls up to the World Health Organization and is used to track public health conditions and mortality rates worldwide.

“SDOH can play an important role in determining a treatment plan for a specific patient,” Dr. Brault notes. “CMS acknowledged this in 2021 by allowing SDOH to be considered when determining the appropriate CPT code for office-based visits. And we expect CMS to do the same for emergency department visits in 2023.”

By including these risk factors in the patient diagnosis, providers can substantiate the increased complexity of these cases. They can also demonstrate the need for higher levels of care and additional care planning.

“Hospitals and emergency departments should identify ways to make patients feel comfortable sharing these details about their living situations,” Dr. Brault advises. “By doing so, clinicians can develop more informed diagnoses and treatment plans with a higher likelihood of success for that individual.”

Dr. Brault also recommends that SDOH be consistently noted in the patient record, so ICD-10 coders can quickly identify them and include them in the coding of the patient chart. This process should also be simple and efficient so as not to overburden staff resources.

Unlike other parts of the medical record, SDOH can be collected by anyone involved in the patient’s care — including clinicians, social workers, community health workers, case managers, patient navigators, and nurses. SDOH can also be collected at intake through screening tools or self-reporting forms.

“This ability to have non-clinicians collect and document this information should result in more complete information capture,” maintains Dr. Brault. “And, ultimately, this should lead to more accurate ICD-10 coding.”

The ICD-10 codes for SDOH can be found in categories Z55-Z65:

  • Z55 – Problems related to education and literacy: This code can apply in cases where a patient is illiterate or schooling is unavailable. It can also apply in cases where a patient is underachieving in school, has not achieved a high school level of education, or has an educational maladjustment.

  • Z56 – Problems related to employment and unemployment: This code relates to patients who are unemployed or those who have recently changed jobs. It can also apply to those who currently face the threat of job loss or have a stressful work schedule. And to patients who have discord with their so-workers or have an unpleasant work environment, including sexual harassment.

  • Z57 – Occupational exposure to risk: This code applies to patients with occupational exposure to noise, radiation, dust, environmental tobacco smoke, toxic agents, or exposure to extreme temperatures.

  • Z58 – Problems related to physical environment: This code applies to patients with inadequate drinking water.

  • Z59 – Problems related to housing and economic circumstances: This code may be suitable for homeless patients, those residing on the street, or those living in a residential institution. This code can also apply to those with food insecurity, low income, or insufficient social insurance or welfare support.

  • Z60 – Problems related to social environment: This code may be appropriate for patients with adverse effects from living alone or those who have trouble adjusting to life-cycle transitions. This code can also apply to those with acculturation difficulty leading to social exclusion, rejection, or targeted discrimination.

  • Z62 – Problems related to upbringing: This code relates to patients with parent or sibling conflicts, including parental overprotection or hostility, inappropriate or excessive pressure, or a history of abuse or neglect in childhood. This code can also apply to patients with inadequate parental supervision, those in child welfare custody, or those with an institutional upbringing.

  • Z63 – Other problems related to primary support group, including family circumstances: This code can be used for patients with disappearances or death in the family or other stressful life events affecting family and household – including family members deployed to the military. This code can also apply to patients who provide home care for an ailing relative. Or those who have family stress due to alcoholism or drug addiction in the family.

  • Z64 – Problems related to certain psychosocial circumstances: This code may be appropriate for patients with an unwanted pregnancy, multiparity, or discord with counselors.

  • Z65 – Problems related to other psychosocial circumstances: This code relates to patients with convictions in civil and criminal proceedings (with or without imprisonment), imprisonment, or other legal circumstances. This code can also apply to patients who have been victims of crimes or terrorism. And those who have had exposure to disaster, war, and other hostilities.

    Article Contributor:
    Dr. Andrea Brault, President and CEO at Brault Practice Solutions.



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