Improving ICD-10-CM Coding for Social Determinants of Health

By Margaret M. Foley, PhD, RHIA, CCS
Social determinants of health (SDOH) are the socioeconomic factors that impact a person’s health. Examples include food insufficiency, limited access to healthcare, social isolation, and unemployment. SDOH have been shown to have a far greater impact on a patient’s health outcomes than either the clinical care provided or genetic factors.1 Healthcare providers and payers are directing significant attention towards SDOH to improve healthcare quality and reduce costs. HIM professionals need to ensure that SDOH information is being captured to support these initiatives, including improving ICD-10-CM coding for SDOH.
Increased Focus on Social Determinants of Health
An increase in value-based purchasing and at-risk payment models has contributed to a greater interested in improving the health of populations being managed.2 Healthcare providers and payers recognize that significant improvements in healthcare cannot be achieved until SDOH are addressed. Many key stakeholders in the healthcare industry have signaled the need to collect, measure, and analyze SDOH.
CMS has developed the following strategies to account for social risks in Medicare’s value-based purchasing program:3

To measure and report quality for beneficiaries with social risk factors
Set high, fair quality standards for all beneficiaries
Reward and support better outcomes for beneficiaries with social risk factors

The Core Quality Measures Collaborative, which is housed at the National Quality Forum, has identified disparities of SDOH as a priority area for quality measure development.4 Healthy People 2030, a data-driven set of national objectives to improve the health and well-being of Americans over the next decade, has a strong focus on SDOH.5 The Office of the National Coordinator for Health IT (ONC) has included support of federal-directed plans that address SDOH in its strategic plan.6 SDOH concepts are also increasingly being used in risk adjustment models to better assess patient outcomes.
Current State of SDOH Documentation and ICD-10-CM Coding
The increased interest in SDOH has led to an expansion in documentation and ICD-10-CM code assignment of SDOH issues. However, SDOH are still not routinely or systematically collected. One study found that only 24 percent of hospitals and 16 percent of physician practices screen for common SDOH. A 2017 survey of hospitals found that while 88 percent of hospitals do screen patients for SDOH, only 62 percent reported systematic or consistent screening of their patient population. Larger healthcare organizations and providers that treat disadvantaged patient populations reported higher screening rates for SDOH. Additionally, standardized terminology is not always used when documenting SDOH.7,8
An analysis of the CMS Chronic Condition Data Warehouse indicates that the five most reported ICD-10-CM SDOH-related Z codes are:9

Z59.0, Homelessness
Z60.2, Problems related to living alone
Z63.0, Problems in relationship with spouse or partner
Z63.4, Disappearance and death of family member
Z65.8, Other specified problems related to psychosocial circumstances

Updates to the ICD-10-CM Official Coding Guideline I.B.14, Documentation by Clinicians Other Than the Patient’s Provider, has made assigning SDOH-related Z codes easier. These updates allow for the use of health record documentation from clinicians involved in the care of the patient who are not the patient’s provider since the information represents social information rather than medical diagnoses. Additionally, patient self-reported documentation may be used to assign SDOH-related codes as long as the patient information is signed-off by and incorporated into the health record by either a clinician or provider. The AHA 4th Quarter 2019 issue of Coding Clinic further clarified that the ICD-10-CM official coding guidelines do not provide a definition for the term “clinicians.” However, for SDOH-related coding, documentation that meets requirements for inclusion in a facility’s health record based on regulatory or accreditation requirements or internal hospital policies may be used.
Current ICD-10-CM codes for SDOH are not sufficient to capture the wide range of SDOH domains and in some circumstances existing codes are not specific enough to reflect different aspects/severity of a domain. For example, there is no code to adequately report transportation difficulties. Furthermore, code Z59.4, Lack of adequate food and safe drinking water, is too broad and is used to capture multiple SDOH concepts. The Gravity Project, an initiative which convenes stakeholders in a collaborative process to develop consensus-based standards to facilitate SDOH data capture and exchange, is addressing these gaps in the ICD-10-CM classification system. The Gravity project will be submitting a request for new codes to the ICD-10-CM Coordination and Maintenance Committee to allow for better capture of various SDOH domains.10
Internal Coding Guidelines
ICD-10-CM code assignment for SDOH is increasing. Many healthcare facilities are developing internal guidelines to facilitate coding and to support organizational efforts to address SDOH. Examples of internal guidelines include:

In accordance with the AHA 4th Quarter 2019 issue of Coding Clinic, identifying the categories of clinicians, such as, community health workers, social workers and case managers whose health record documentation may be used for SDOH code assignment.
Identifying documentation that would justify the assignment of an SDOH-related ICD-10-CM code. For example, documentation of “Tent City” resident or “Lives in vehicle” would justify the reporting of code Z59.0, Homelessness. Code Z56.6, Other physical and mental strain related to work, is to be assigned for documentation of patient being furloughed, underemployed, or reporting reduced work hours.
Reporting SDOH-related codes on readmission records to support the healthcare organization’s readmission reduction program.
Requiring the reporting of SDOH-related codes on all well child visits to meet a state Medicaid requirement that this information be included on the claim.
Requiring that SDOH-related ICD-10-CM codes be reported in the top 25 diagnosis fields to ensure that the information is included on claims submitted to payers.

Steps to Improve ICD-10-CM Code Assignment for SDOH at Your Facility
Efforts to improve coding for SDOH must start with an assessment of the organization’s SDOH-information needs and the current state of SDOH documentation. Ideally, a multi-disciplinary team comprised of healthcare providers, (including population health specialists, clinicians representing the staff that document the non-medical SDOH information), coding and CDI professionals and information technology staff responsible for EHR development should be convened. Given the resources available that can be dedicated to improve the coding for SDOH, organizations may opt to start with a pilot focusing on a single SDOH domain such as food insecurity or homelessness.
Some concrete steps that HIM professionals can take to improve the ICD-10-CM coding of SDOH include:

Generate reports to determine which SDOH codes are being assigned. Review a sampling of records to assess the types of cases and documentation for which the codes were assigned.
Meet with clinicians that document SDOH concepts to determine the best health record sources to capture this information.
Develop internal coding guidelines to identify the categories of clinicians (e.g. community health worker, case manager) from whom documentation can be used for code assignment and the likely location of this information in the health record.
Ensure that CDI and coding staff have access to and are aware of all the locations in the EHR where SDOH information may be documented.
Educate CDI and coding staff on the importance of SDOH code assignment.
Educate providers and clinicians on the importance of consistently documenting SDOH information.
Work with staff responsible for computer assisted coding products to create logic for the review of SDOH documentation and generation of suggested ICD-10-CM codes.
Monitor for improvement (increased reporting) of SDOH code assignment by patient type, diagnosis, provider and SDOH domain.
Conduct audits on the quality of SDOH documentation and ICD-10-CM coding accuracy. Provide feedback, as needed. For example, if needed, request EHR templates be developed to support more complete capture of SDOH information.

As providers, health systems, and payers continue to address SDOH, the ability to analyze patient outcomes and assess the effectiveness of various initiatives will be essential. HIM professionals must act now to be able to support these goals to improve health outcomes and reduce costs.

Schroeder, Steven A. “We Can Do Better — Improving the Health of the American People .” New England Journal of Medicine 1221-1228: 2007.
Deloitte Center for Health Solutions. “Social Determinants of Health: How Are Hospitals and Health Systems Investing in and Addressing Social Needs?” 2017.
US Department of Health & Human Services’ Office of the Assistant Secretary for Planning and Evaluation. “Social Risk Factors and Performance in Medicare’s Value-Based Purchasing Program.” 2020.
The Core Quality Measures Collaborative. 2020. “Analysis of Measurement Gap Areas and Measure Alignment.”
US Department of Health and Human Services’ Office of Disease Prevention and Health Promotion. Social Determinants of Health. Accessed December 6 2020.
Office of the National Coordinator for Health IT. “Federal Health IT Strategic Plan 2015-2020.” 2015.
Fraze, Taressa K. et al. “Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals.” Journal of the American Medical Association Network Open 2 (9): 2019. doi:doi:10.1001/jamanetworkopen.2019.11514.
US Department of Health and Human Services’ Office of the Assistant Secretary for Planning and Evaluation, ibid.
Centers for Medicare and Medicaid Services’ Office of Minority Health. “Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017.” 2020.
The Gravity Project. “Announcements.” November 2020.

Margaret M. Foley is associate professor at Temple University.

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