Coding for Social Determinants of Health

August 28, 2023

Here’s a sobering thought for healthcare professionals: According to the National Academy of Medicine, medical care accounts for only 10% to 20% of all health outcomes. Social Determinants of Health (SDOH) account for most of the remaining factors.

Until the preceding decade, SDOH received little attention in medical texts—and none in medical coding mechanisms. However, that has rapidly changed. SDOH is now one of the three priority areas in Healthy People 2030, a set of data-driven national objectives released by the Centers for Disease Control and Prevention. Furthermore, the Z-codes, created in 2015 and expanded in 2023, are becoming increasingly critical for E/M coding and Medical Decision-Making.

What is SDOH?

As defined by the CDC, “Social Determinants of Health (SDOH) are the non-medical factors influencing health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”2

A few examples of SDOH include:

  • Safe housing, transportation, and neighborhood
  • 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

sdoh

SDOH contributes to health disparities and inequities. For example, people lacking access to grocery stores with nutritious options are more likely to experience poor nutrition. This would raise their risk of health conditions, such as heart disease, diabetes, and obesity—and may even reduce their life expectancy when compared to those with access to nutritious options. As highlighted by the AMA, “SDOH factors may raise the risk of complications, morbidity or mortality by limiting treatment options and diagnosis capability.”3

 

1 National Academy of Medicine, Social Determinants of Health 101 for Health Care, https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five/

2 Centers for Disease Control and Prevention, “Social Determinants of Health at CDC,” https://www.cdc.gov/about/sdoh/index.html

3 American Medical Association, “Social determinants of health and medical coding: What to know,” May 13, 2023, https://www.ama-assn.org/practice-management/cpt/social-determinants-health-and-medical-coding-what-know#:~:text=For%20instance%2C%20with%20use%20of,treatment%20options%20and%20diagnosis%20capability.

4 AAPC, “Coding SDOH Takes Practice,” https://www.aapc.com/blog/84911-reporting-social-determinants-of-health/

 

The Five Pillars of SDOH4

1. Economic Stability: Focused on the connection between people’s financial resources, cost of living, and health.

In the United States, 1 in 10 people live in poverty, and a significant number of individuals struggle to afford healthy foods, healthcare, and housing. The challenges of poverty, unemployment, food insecurity, and housing instability can profoundly impact an individual’s health status and their capacity to afford and adhere to prescribed medical treatment. Healthy People 2030 focuses on helping more people achieve economic stability.  (Codes associated with economic stability include Z56 and Z59).

2. Education Access and Quality: Focused on the relationship between education and health. and adolescents do well in school.

Children from low-income families, those with disabilities, or those who face social discrimination often encounter challenges with math and reading skills. Consequently, they exhibit a lower likelihood of completing high school and pursuing higher education. The strain associated with living in poverty can also negatively impact brain development, thereby impeding children’s academic success. Healthy People 2030 places a specific emphasis on expanding educational opportunities and implementing interventions that support scholastic achievement among children and adolescents, which can have long-term health benefits. (Codes associated with this objective include Z55 and Z62).

3. Healthcare access and quality: Focused on connections between people’s health and their access to and understanding of health services.

Many people in the United States don’t get the healthcare services they need due to lack of access, lack of health insurance coverage, and inadequate health literacy. Healthy People 2030 focuses on improving health outcomes by improving access to comprehensive, quality preventive care and treatment for chronic illnesses. (Codes associated with healthcare access and quality include Z55, Z56, and Z91.120).

4. Neighborhood and Built Environment: Focused on connections between where a person lives and their health.

The quality of housing, access to transportation, availability of nutritious foods, water quality, the prevalence of neighborhood violence, and exposure to unhealthy work environments (such as second-hand smoke or loud noises) collectively influence an individual’s health risk. Addressing these factors, which disproportionately affect low-income populations, helps create environments that promote health and safety. (Codes associated with this objective are Z58 and Z59).

5. Social and Community Context: Focused on the context within which people live, learn, work, and play.

Numerous individuals encounter adversities beyond their control that negatively impact their health and risk levels. These challenges encompass unsafe neighborhoods, experiences of discrimination, the presence of incarcerated parents or spouses, and instances of school bullying. Healthy People 2030 aims to increase social and community support to improve health and well-being. (Codes associated with social and community context are Z57 and Z60-Z65).

 

Next week, we’ll focus on how to collect and apply the proper Z-codes.

 

Got a question about E/M coding? We’d love to hear from you.

Submit your questions by emailing us at coder@calmwatersai.com!


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