Q&A: Reporting SDOH in ICD-10-CM
Q: What are some tips for organizations that are just starting out capturing the type of information to report social determinant of health (SDOH) diagnoses in ICD-10-CM?
A: Codes with generally no reimbursement impact can be considered unimportant to capture for some, but obtaining and reporting this data can have both medical and non-medical impacts on patient care. Before any data collection or strategies for management can even be considered, however, the information has to be in the documentation to be able to be reported.
Therefore, the first step of the process is education. Educating providers, including nursing, case managers, and non-physician clinicians—the people creating the documentation—on how important it is to document these SDOH will be vital in the beginning of the process. Educating CDI professionals would also be a great place to start, because they interact with providers and nursing staff.
According to the 2023 ICD-10-CM guidelines, “There are a few exceptions when code assignment may be based on medical record documentation from clinicians who are not the patient’s provider.” Reporting SDOH, such as those in categories Z55-Z65 (persons with potential health hazards related to socioeconomic and psychosocial circumstances), is one of those exceptions.
In other words, when reporting SDOH, the documentation can come from non-physician providers, such as counselors, as long as it has been signed off by the patient's provider and the associated diagnosis has also been documented by the patient's provider.
The next step would be developing a process for capturing these codes. Providers and coding managers can look to documentation tools that their organizations may already have in place as part of their electronic health record systems.
Documentation can also be self-reported, according to the 2023 ICD-10-CM guidelines. Coders can utilize that EHR to capture that self-reported data in a way that providers can sign off on. Then, that information can be utilized for coded data.
The process will likely take some trial and error, as each facility operates differently. But education and communication between departments will be vital for documenting and reporting SDOH.
Editor’s note: This article originally appeared in JustCoding. This question was answered by Kimberly Cunningham, CCS, CPC, instructor for the Certified Coder Boot Camp programs at HCPro in Middleton, Massachusetts, during the webinar, “Solidify ICD-10-CM Coding for Social Determinants of Health.”