Coding & Quality Measures Tip: Social Determinants of Health
RHIA, CDIP, CCS, CCS‑P, CIRCC
Executive Director Of Education
AHIMA‑Approved ICD‑10‑CM/PCS Trainer and Ambassador
Our Coding & Quality Measures Series discusses how coding may adversely affect your quality statistics and bottom line. For this week’s tip, our Executive Director of Education, Patricia Maccariella-Hafey, RHIA, CDIP, CCS, CCS-P, CIRCC explores the “Social Determinants of Health” and coded data.
The HIM world has been buzzing recently with discussion of “Social Determinants of Health” and coded data. What does this mean for coders and the HIM field?
What Are Social Determinants of Health?
First, let’s discuss what they are. Social determinants of health, oftentimes abbreviated as (SDOH) are the economic and social conditions in which people are born, live, grow, work and age in. They may impact a wide range of health and quality of life risks and outcomes for patients. What are they? They can be things such as a history of physical abuse, homelessness, economic circumstances affecting health care, social exclusion and rejection, and problems related to education and literacy. Although these types of determinants may be documented within the medical record, they may not always be coded by coders.
They are best captured by the ICD-10-CM codes within Chapter 21: Factors influencing health status and contact with health services (Z00-Z99). Below are some of the broad categories of SDOH codes:
Persons with potential health hazards related to socioeconomic and psychosocial circumstances (Z55-Z65)
- Z55 Problems related to education and literacy
- Z56 Problems related to employment and unemployment
- Z57 Occupational exposure to risk factors
- Z59 Problems related to housing and economic circumstances
- Z60 Problems related to school environment
- Z62 Problems related to upbringing
- Z63 Other problems related to primary support group, including family circumstances
- Z64 Problems related to certain psychosocial circumstances
- Z65 Problems related to other psychosocial circumstances
How Are Social Determinants of Health Codes Used?
The data collected from claims with reported SDOH codes is being used by CMS to analyze data and health trends. This document by CMS highlights how CMS is using the data: https://www.cms.gov/files/document/cms-omh-january2020-zcode-data-highlightpdf.pdf
For example, of the 33.7 million total Medicare fee for service beneficiaries in 2017, approximately 1.4% had claims with Z codes. The 5 most utilized Z codes from this article were:
- Z59.0 – Homelessness
- Z60.2 – Problems related to living alone
- Z63.4 – Disappearance and death of family member
- Z65.8 – Other specified problems related to psychosocial circumstances, and
- Z63.0 – Problems in relationship with spouse or partner
The worse conditions have been shown to negatively affect outcomes such as hospital readmission rates, length of stay, and use of post-acute care services. A 2014 National Academies of Medicine (NAM) report suggested that the collection of SDOH data in an electronic health record Is necessary to empower providers to address health disparities and to support further research on the effects of SDOH.
For example, of the 467,136 Medicare FFS beneficiaries in 2017 with Z code claims, 334,373 individuals which represents 72% had hypertension, and 248,726 individuals which is 53% had depression. You can see where the use of the SDOH data can be helpful in various ways.
The data source for the study in Medicare claims came from the CMS Chronic Condition Data Warehouse (CCW) (www.ccwdata.org)
What is a Coder to Do?
Coders are not new to “Z” codes and have frequently assigned these for things such as personal and family histories, statuses and for long term use of drugs, among other things. Coders should become familiar with Z codes that include SDOH if they have not already. Usually coders put little emphasis and time on finding SDOH in the EHR and coding them. However this is changing and coders should begin to identify the documented SDOH and code them in ICD-10-CM when documented and codes are available. They do not necessarily have to be documented by the actual physician or provider. According to AHA Coding Clinic, 1Q2018 page 18, categories Z55-Z65 are acceptable to report based on information documented by other clinicians involved in the care of the patient. That means that coders can code SDOH from nursing and other documentation.
The coder should check with their facility to see if there are specific areas in the EHR where this is documented if it is not evident. Coders are going to be seeing the documentation of SDOH increasing. I encourage all coders to read the article in the link below under “References” so they can see the breadth of the use of this data.
As we can see above, the use of coded data is becoming more and more robust and required in an ever changing healthcare world.
The information contained in this post is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
Why are so many AKI records being denied? It’s hard to give one answer for why so many AKI records are being denied lately, but most appear to be due to the multiple sets of criteria available for use in determining if a patient has AKI, as well as physician documentation. As stated in Part 3 of this series, there are three main criteria/classifications used to diagnose AKI.
In previous parts of this series we looked at the definitions of AKI/ARF, causes, coding and sequencing, and the common clinical indicators that patients present with that are diagnosed with this condition. In Part 4, we will look at the documentation that should be present to report the diagnosis without fear of denial, as well as when a query is needed to clarify the diagnosis.
If the facility does a COVID-19 test, and test is negative, do I need a diagnosis code. The answer is yes, you will report a Z-code. The Z-code depends on the record documentation and circumstances of testing. For any patient receiving a COVID-19 test, if negative, there MUST e a Z-code to describe why the test was taken. (Test negative for COVID-19 and MD does not override negative results).
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As discussed in Part 1 of this series, AKI/ARF is a common diagnosis that coders see daily. In Part 2, we are going to focus on the different types/specificity of AKI/ARF. We’ll learn what they mean, as well as how to code the diagnosis.
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The biggest reasons why some hospital systems are moving to single path coding is to eliminate duplicative processes and to optimize productivity. In addition, costs are reduced when only one coder “touches” the record and completes both types of coding.
Effective with 4/1/2020 discharges, ICD-10-CM code U07.0 is used to report vaping -related disorders. ICD-10-CM code U07.0 (vaping related disorder) should be used when documentation supports that the patient has a lung-related disorder from vaping. This code is found in the new ICD-10-CM Chapter 22. U07.0 will be in listed in the ICD-10-CM manual under a new section: Provisional assignment of new disease of uncertain etiology or emergency use.
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This is part two of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. In this part, we discuss mismatches and how to best go about resolving them. In part three we will provide a case example of best practice interaction.
This is part one of a three part series in which we address how coders can better interact with Clinical Documentation Improvement (CDI) professionals. Many times these departments are separate and the remote environment makes it difficult to interact efficiently between the two departments. In part one, we will discuss the history and objectives of CDI so the coder has a better understanding of CDI’s role.
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For Part 1 of this 5-part series, we will look at Chapter 21 within ICD-10-CM—Z00-Z99—Factors influencing health status and contact with health services. There is no possible way to include every guideline or coding reference for this chapter, but I’ll do my best to touch on some off the most common issues.
In response to the recent occurrences of vaping related disorders and in consultation with the World Health Organization (WHO) Framework Convention on Tobacco Control, the WHO Family of International Classifications (WHOFIC) Network Classification and Statistics Advisory Committee (CSAC) was convened to discuss a diagnosis code for vaping related illness for immediate use.
We’re finally at the #1 most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. Most have probably already guessed what the correct DRG would be with the most recommendations. There are just some diagnoses and DRG’s that will always be a thorn in the side for coders. #1 DRG with the most recommendations during HIA reviews : DRG 871—Septicemia or severe sepsis w/o mechanical ventilation >96 hours with MCC
We’re now at the second most common DRG with recommendations by HIA for 2019. Just to recap, HIA reviewed over 50,000 inpatient records in 2019. We are counting down to # 1. #2 DRG with the most recommendations during HIA reviews: DRG 872—Septicemia or severe sepsis w/o mechanical ventilation >96 hours w/o MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #3 DRG 190—Chronic obstructive pulmonary disease with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #4 is DRG 193—Simple pneumonia & pleurisy with MCC.
In 2019, HIA reviewed over 50,000 inpatient records. Wow! That is a lot of records. Even with this large number of records, the DRG’s with recommendations are still the ones that coders typically see during audits. #5 DRG with the most recommendations during HIA reviews : DRG 853—Infectious & Parasitic diseases with O.R. procedure with MCC
Pivotal moments in the Health Information Management field include the implementation of ICD-10, CPT Coding Changes, Acute care changes, profee changes, recovery audit contractor implementation, new ransomware challenges, Meaningful use and much more.