Documenting and Coding for Social Determinants of Health
Social Determinants of Health (SDoH) are economic or social conditions in the environment that can affect individuals’ health and quality-of-life outcomes.
Social determinants of health can be broken out into five groups:
· Economic Stability
· Education Access and Quality
· Health Care Access and Quality
· Neighborhood and Built Environment
· Social and Community Context
Examples of SDoH:
· Safe housing, transportation, and neighborhoods
· Racism, discrimination, and violence
· Education, job opportunities, and income
· Access to nutritious foods and physical activity opportunities
· Polluted air and water
· Language and literacy skills
The above Social Determinants result in a patient whose care management is considered Moderate Risk, 99204/99214. You medical record must contain the documentation to support and SDoH.
CMS and the CDC have established ICD-10 codes to help track patients who are affected by one (or more) of the five groups of Social Determinants of health in an effort to produce better outcomes.
The following links contain helpful information for documenting and choosing a diagnosis code for patients affected by Social Determinants of Health.
Using Z Codes: The Social Determinants of Health from CMS.gov
Improving the Collection of Social Determinants of Health (SDOH) Data with ICD-10-CM Z Codes
If you need any additional information or guidance regarding Social Determinants of Health as it relates to your practice, please contact Jana Holt at jholt@medicalpmrg.com