More information on reporting codes for social determinants of health

The Centers for Disease Control and Prevention (CDC) National Center for Health Statistics (NCHS) has clarified who can document and assign ICD-10 codes related to patients’ unmet social needs. Codes in categories Z55-Z65 describe patients with potential health hazards related to socioeconomic and psychosocial circumstances, commonly known as social determinants of health (SDOH). The CDC announced the addition of 11 new Z codes last summer. The codes went into effect Oct. 1.

The SDOH Z codes represent information rather than a diagnosis and may be assigned based on medical documentation by clinicians involved in the patient’s care, even if they are not the patient’s medical provider. For example, coders may use documentation from social workers, community health workers, case managers, or nurses if their information is included in the official medical record. Additionally, patients’ self-reported documentation may be used as long as a clinician or provider signs off on the information and incorporates it into the medical record.

Additional information on Z codes is available in the Centers for Medicare & Medicaid Services’ infographic “Using Z Codes: The Social Determinants of Health Data Journey to Better Outcomes.” For guidance on ICD-10 coding, review the ICD-10-CM Official Guidelines for Coding and Reporting FY 2022. 

— Erin Solis, manager of practice and payment, American Academy of Family Physicians

Posted on Jan. 3, 2022, by Erin Solis