Why (and How) You Should Use ICD-10 Codes for Social Determinants of Health
By Joy Woodke, COE, OCS, OCSR, Academy Director of Coding and Reimbursement, and Flora Lum, MD, Academy Vice President, Quality and Data Science
ICD-10 includes codes that represent social determinants of health (SDOH). Your practice’s use of these codes can support both your E/M coding and the work of analysts who use the IRIS Registry or payers’ databases for their studies. Here’s how.
Z Codes for SDOH
ICD-10’s Z codes are for circumstances that may impact health but are not in themselves a current illness or injury. Subchapter Z55-Z65 features SDOH codes, including the following:
- Z56.0 Unemployment, unspecified
- Z59.01 Sheltered homelessness
- Z59.02 Unsheltered homelessness
- Z59.7 Insufficient social insurance and welfare support
- Z62.21 Child in welfare custody
Use as a secondary diagnosis. Z codes typically are not payable when reported as a primary diagnosis.
Document the SDOH. The medical record should document the patient’s potential barriers to diagnosis and treatment due to their unique SDOH.
SDOH and E/M Coding
Levels of medical decision-making. If you use an E/M code to bill for an office visit, the level of E/M code that you can use depends on the overall complexity of medical decision-making (MDM), which can be straightforward or of low, moderate, or high complexity.
Three parts to MDM. MDM is broken down into three components:
- Problems—“the number and/or complexity of problems addressed at the patient encounter”
- Data—“the amount and/or complexity of data to be reviewed and analyzed”
- Risk—“the risk of complications and/or morbidity or mortality of patient management”
When selecting the overall level of MDM complexity, first consider the complexity level of each component. If, for example, a patient has two or more stable chronic illnesses, the problems component would point to MDM of moderate complexity. If the three components each point to a different level of MDM, then the middle one would determine the overall level of MDM. If at least two components indicate the same level of MDM, then that would determine the overall level of MDM.
SDOH can affect the risk component of MDM. Suppose, for example, a glaucoma patient has lost his job and health insurance. As a result, he can’t afford his drops and declines a recommended OCT and visual field testing. This significantly limits the ophthalmologist’s ability to confirm the progression and severity of the disease and impacts the patient’s treatment and his ultimate outcome. When diagnosis or treatment is significantly limited, the risk component of MDM would support an overall level of MDM of moderate complexity. If at least one other component of MDM supports the same overall level of MDM, then you would be able to submit a level 4 E/M code—CPT code 99204 for a new patient or 99214 for an established one. Make sure that the SDOH is documented, and report the appropriate ICD-10 Z code as a secondary diagnosis, linking it to either 99204 or 99214.
Resources. For E/M guidance, see aao.org/em. For more on ICD-10 codes, visit aao.org/icd10 and consider buying 2022 ICD-10-CM for Ophthalmology at aao.org/codingproducts.
How to Support Insights Into Disparities of Care
The Academy Task Force on Disparities in Eye Care was charged with providing an understanding of current knowledge about visual health and disparities, as well as identifying gaps in data. Meanwhile, the Academy IRIS Registry is being used to identify and evaluate disparities in eye care access and outcomes.
What you can do. Your practice can help to support these initiatives by including the ICD-10 Z codes for SDOH. Use of these codes will provide greater specificity about patient circumstances that could affect their health outcome, building a foundation to identify scientific insights about which patients are affected and what their outcomes of care are, and ultimately leading to future studies on how to address disparities in care.