Coding Background Image

Exceptional Coders | Innovative Technology

Hospitals Now Allowed to Use Non-Physician Documentation to Support Coding for Social Determinants of Health

Posted by David Fong on Jul 26, 2018 7:00:00 AM

A recent Becker’ Hospital CFO Report  article noted the changing of the rules governing reporting of social determinants of health following the American Hospital Association's diligent work. The association said the ICD-10-CM Cooperating Parties, including AHIMA, AHA, CMS and the National Center for Health Statistics, approved advice published by the AHA Coding Clinic that allows hospitals to report ICD-10-CM codes included in categories Z55-Z65, based on documentation from all involved caregivers, including non-physicians. That change took effect in February of this year.


Social Determinants of HealthSocial determinants include food, housing, transportation, education, violence, social support, health behaviors, and employment, among other societal and environmental conditions. To report such issues, hospitals and health systems use ICD-10-CM codes included in categories Z55-Z65. The categories include "problems related to education and literacy," "problems related to employment and unemployment," and "occupational exposure to risk factors," among others.


While these codes were available, coding professionals could only report them if there was supporting physician documentation, according to the AHA, which cites the ICD-10CM Official Guidelines for Coding and Reporting. This means hospitals and health systems could not report societal and environmental conditions if documentation was supported by non-physician providers, such as case managers, discharge planners, social workers and nurses.  This new rule will go a long way to present a more accurate picture of a patients’ social determinants that can greatly affect their health status.

Topics: Medical Coding, Clinical Documentation, Outsourcing