Topic: Social Determinants of Health

Definition: Social determinants of health (SDOH) are the nonmedical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, worship, and age.

Diagnostic Criteria:

• Codes describing social problems, conditions, or risk factors that influence a patient’s health should be assigned when this information is documented in the patient’s medical record.  

Coding Considerations:

• Coders can utilize non–physician documentation of SDOH from social workers, community health workers, case managers or nurses, if the documentation is included in the official medical record. 
• In addition, patient self-reported documentation if signed off and included in the medical records by a clinician or provider can be utilized for the SDOH codes.
• Consider the following Coding Clinics:
  • AHA Coding Clinic, Fourth Quarter 2019, p. 66: If the patient’s self-reported information is incorporated into the health record by either a clinical or provider, it would be appropriate to assign codes from categories Z55-Z65 describing social determinants of health.
  • AHA Coding Clinic, Fourth Quarter 2019, p. 67: The ICD-10-CM Official Guidelines for Coding and Reporting do not have a unique definition of the term clinicians. In the context of code assignments for social determinants of health, internal hospital policies could be utilized to identify the documentation used to support code assignment, as this information pertains to social rather than medical information.
  • AHA Coding Clinic, First Quarter 2018, p. 14: Instructs that categories Z55-Z65, Persons with potential health hazards related to socio-economic and psychosocial circumstances, represent social information rather than medical diagnoses. It is acceptable to report those codes based on information documented by other clinicians other than the patient’s provider who are involved in the care of the patient.  

CDI Practice Considerations:

• Assign as many SDOH codes as necessary to describe all the social problems, conditions, or risk factors documented during the current episode of care. 
• Codes should ONLY be assigned when the documentation reflects an actual problem or risk factors.  For example, not every individual living alone should be assigned Z60.2, problems related to living alone. 
• Including Social Determinants of Health (SDOH) in clinical documentation not only provides a more accurate representation of a patient’s clinical complexity and resource needs but also influences various risk adjustment models—such as value-based care programs and Hierarchical Condition Category (HCC) scoring. Additionally, certain SDOH-related codes, listed below, are recognized as Complications or Comorbidities (CCs), potentially impacting MS-DRG assignment and reimbursement. 

Query Opportunity:

• If the patient has a prior history of risk factors or problems associated with any Z codes, but lacks supporting documentation on this stay, an opportunity may exist to query for the specific Z code.  

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