When you post coding questions on social media or in group chats, always specify if your question is payer-specific.
Use caution because a general question will yield a general answer that may not apply to a specific payer.
I’ve seen questions from coders asking if codes are payable or why a code was denied.
Always reach out to the payer. Even if the patient has Medicare, each Medicare Administrative Contractor (MAC) may have different policies depending upon the locality.
Social determinants of health are economic and social conditions that influence people and communities’ health and affect health and quality of life risks and outcomes.
Problems related to housing and economic circumstances
Problems related to social environment
Problems related to upbringing
Other problems related to primary support group, including family circumstances
Problems related to certain psychosocial circumstances
Problems related to other psychosocial circumstances
Within each category are subcategories and subclassifications that provide detailed descriptions.
For example:
Z63®is the category to describe Problems related to primary support group including family circumstances. Z63® is not a complete code. It requires a 4th digit (found in Z63® subcategory) of either .0 or .1.
Within the Z63® category is subcategory Z63.3® (not a complete code) to specify absence of family member, which requires the 5th digit of .1 or .2 (subclassification).
Why should providers document SDOH?
Providers should document circumstances for the encounter that may impact patient care/treatment and follow-up, or circumstances that may complicate care and increase the risk of complications and/or morbidity or mortality of patient management.
Section I.B.14 Documentation by Clinicians Other than the Patient’s Provider
“For social determinants of health, such as information found in categories Z55- Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”
Chapter 21: Factors influencing health status and contact with health services “Use of Z Codes in Any Healthcare Setting Z codes are for use in any healthcare setting. Z codes may be used as either a first-listed (principal diagnosis code in the inpatient setting) or secondary code, depending on the circumstances of the encounter.”
Of course, providers should not just document the circumstances. They should address social determinants of health to improve outcomes and health equity.
The AMA provides a free online education module for healthcare professionals and coders (once you create an account).
Reviewed and Analyzed, and Risk of Complications and/or Morbidity or Mortality of Patient Management) for that level of medical decision-making must be met or exceeded.
We’re focusing on Risk of Complications and/or Morbidity or Mortality of Patient Management because Diagnosis or treatment significantly limited by social determinants of health is included in the Moderate category.
When providers document circumstances that describe SDOH and its relevance to that encounter, coders should assign the ICD-10-CM code as an additional diagnosis. When abstracting the E/M level, coders should look to the Moderate category.
ICD-10® is copyrighted by the World Health Organization (WHO)
In a previous blog, “Prove Them Wrong” Part 2 (Coding from the Findings), I shared why coders should not assign diagnoses codes from the Findings and why, if the findings are clinically relevant, providers should document them in the Impression.
I also cited references from ICD-10-CM, Coding Clinic, and the American College of Radiology (ACR) to support that coders should not code from the findings, but they can use information in the findings for specificity such as laterality or body area:
ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page: 5 Effective discharges: March 13, 2017.
ICD-9-CM Coding Clinic, Second Quarter 1990 Page: 15 to 16 Effective with discharges: April 1, 1990, clarifies that “Nonspecific abnormal findings, should be assigned only when the physician has not been able to arrive at a diagnosis based on an abnormal finding, but considers it clinically significant enough to list in the final diagnostic statement.”
According to the American College of Radiology (ACR) Practice Parameter for Communication of Diagnostic Imaging Findings, A. Components of the Report, the recommended format should include (in addition to Clinical Indication and Technique), Findings and Impression (conclusion or diagnosis) sections and, “Unless the report is brief, each report should contain an “impression” or “conclusion.”
Coders are not clinicians. We do not diagnose patients. If you are a clinician who also codes, you are not diagnosing the patient in your role as a coder.
As coders, our job is to translate the documentation into codes to tell the patients’ stories written by the provider who is treating and diagnosing the patients.
Suppose the provider does not document a “finding” in the final interpretation (impression). In that case, there could be a documentation issue that requires a query, or it could be that the finding is not clinically relevant to why the patient presented for the service (an incidental finding).
Let’s review some examples:
Clinical indication is history of prostate cancer, rule out metastatic disease. Provider performed CT of chest, abdomen, and pelvis and documented in the impression no CT evidence of metastatic disease. In the findings, the provider documented unchanged atelectasis/scarring in the right lung base, atherosclerosis of the thoracic aorta, degenerative changes of the visualized spine, and chronic pancreatitis.
The coder assigned ICD-10-CM codes for abnormal findings of the lung, atherosclerosis of the aorta, and chronic pancreatitis – all from the findings. The coder did not even assign a diagnosis code for a history of prostate cancer.
Yes, the provider documented all of the conditions in the findings but did not document them in the impression. The patient was seen to rule out metastatic disease because of his history of prostate cancer.
Question for the coder: How did you determine that the diagnoses you abstracted from the findings were clinically relevant to ruling out metastatic disease in a patient previously treated for prostate cancer when the interpreting provider did not document them as clinically relevant (in his interpretation)?
The clinical indication is shortness of breath, and the provider documented bilateral pulmonary opacities consistent with bilateral pneumonia that should be followed to radiographic resolution in the impression.
The coder assigned the ICD-10-CM code for lung cancer instead of the diagnosis code for the abnormal finding (opacities) in the lung field.
Where did the coder find that in the note? In the findings, the provider documented pulmonary opacities bilaterally and that these should be followed to radiographic resolution to exclude underlying malignancy.
So, this coder went to the Findings to “diagnose” the patient with lung cancer. Big mistake!
Provider documented clinical indication, irregular menses, and performed a sonohysterogram. The provider documented an “unremarkable study” in the impression, and the coder assigned ICD-10-CM code for irregular menses. In the findings, the provider documented multiple uterine leiomyomas.
In this scenario, I would have queried the provider for the clinical significance of multiple uterine leiomyomas in the findings. According to the American College of Gynecology (ACOG), irregular menstruation may be a symptom of fibroids.
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ICD-10® is copyrighted by the World Health Organization (WHO)
Coffee With a Medical Coding Auditor 