Q&A: Assigning SDOH codes

Q: Our organization has implemented a workflow to identify social determinants of health (SDOH). The tool is provided to patients at annual visits and Medicare annual wellness visit. I feel that the question which would lead to the assignment of SDOH code Z55.9, Problems related to education and literacy, is subjective. The question asks whether the patient is “interested in more education.”

Would a “yes” answer be enough to assign code Z55.9? What’s your opinion?

A: This is a great question. From a coding perspective, we can never make assumptions when assigning codes and that includes the SDOH.

We can, however, apply these codes if documented by individuals other than the provider (see American Hospital Association [AHA] Coding Clinic, first quarter 2018, p. 18). We also have guidance within Coding Clinic, fourth quarter 2019, p. 66, that says that patient self-reported information would be appropriate to support assignment of codes from categories Z55-Z65, describing SDOH if it is signed-off and incorporated into the health record by either a clinician or provider.

The question aimed at reporting code Z55.9, in my opinion, does not provide enough for the coding professional to assign that code. They’d need more information. 

For example, if you asked me the same question this morning, I would have answered yes! However, I would have been referring to a college course, or my desire to learn about retiling a bathroom, or learning how to trim my rose bushes. Answering yes doesn’t lead to the specific needed to identify a problem nor the need for specific counseling.  

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O, CDI education director at HCPro in Middleton, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps, click here.