Basics of Social Determinants of Health (SDOH)
SDOH consist of the following five domains:
- Economy: a person’s access to employment, their employment status, stability of employment, income, and poverty level.
- Education: a person’s ability to reach their highest level of education, which is related to access to quality day care, schools, and adult education.
- Health care: a person’s access to high-quality health care, insurance, and other health care needs.
- Physical infrastructure: a person’s neighborhood and physical environment and the availability of housing, transportation, food, green spaces, and safe air and water.
- Social and community: a person’s social and community network, including social support, cohesion, and demographics (eg, race, ethnicity, religion, gender).
How to Use Z Codes for Social Determinants of Health (SDOH)
ICD-10 CM Coding for SDOH
Chapter 21 of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code set includes a block of Z codes that are used to report SDOH information. In 2019, the American Medical Association (AMA) collaborated with United Healthcare® on its request to the ICD-10-CM Coordination and Maintenance Committee to create 23 new codes for capturing SDOH factors.
See Table 2 for a list of the ICD-10-CM Z-code categories for persons with potential health hazards or factors related to socioeconomic and psychosocial circumstances, which are the SDOH.
| Table 2. ICD-10-CM Z-Code Categories and Influencing Factors | |
|---|---|
| Z-Code SDOH Categories | Examples of Influencing Factors |
| Z55: Problems related to education and literacy | Illiteracy and low-level literacy, lack of schooling, underachievement in school, less than a high school diploma or general equivalence degree (GED). |
| Z56: Problems related to employment and unemployment | Unemployment, threat of job loss, stressful work schedule, difficult relationships with boss or co-workers, difficult working conditions, sexual harassment. |
| Z57: Occupational exposure to risk factors | Exposure to noise, radiation, dust, tobacco smoke, toxic agents, extreme temperatures. |
| Z58: Problems related to physical environment | Lack of or inadequate safe drinking water. |
| Z59: Problems related to housing and economic circumstances | Homelessness, inadequate housing, housing instability, difficulties with neighbors or property owner, lack of food, extreme poverty, low income, financial insecurity, transportation insecurity, material hardship including inability to obtain childcare. |
| Z60: Problems related to social environment | Life-cycle transitions, difficulties due to migration, social rejection, discrimination. |
| Z62: Problems related to upbringing | Lack of parental supervision, overprotective parenting, welfare custody, physical abuse, psychological abuse, neglect, parent-child estrangement. |
| Z63: Other problems related to primary support group, including family circumstances | Problems with spouse/partner, family separation or divorce, military deployment of a family member, alcoholism or drug dependency in the family. |
| Z64: Problems related to certain psychosocial circumstances | Unwanted pregnancy, multiple birth children, discord with counselors (eg, probation officer, social worker). |
| Z65: Problems related to other psychosocial circumstances | Civil or criminal proceedings, incarceration, child custody proceedings, victim of a crime, exposure to a disaster or war, etc. |
When coding the patient’s medical record, the coder identifies in the documentation any appropriate social factors and includes them in the claim with the other diagnosis codes related to the services provided. Including Z codes in the claim enables the health plan to capture information about the patient’s social needs and health factors. These codes are also included in claims-based public health reporting efforts.
Read also: When to use add-0n code G2211 by medical coders
When to bill G0136 code
We finalized a new stand-alone G code, G0136, to pay for administering an SDOH risk assessment, no more than once every 6 months:
G0136: Administration of a standardized, evidence-based SDOH assessment, 5–15 minutes, not more often than every 6 months.
You may provide this service with:
● An evaluation and management (E/M) visit, which can include hospital discharge or transitional care
management services
● Behavioral health office visits, such as psychiatric diagnostic evaluation and health behavior assessment and intervention
● The Annual Wellness Visit (AWV)
SDOH risk assessments that you furnish as part of an E/M or behavioral health visit isn’t a screening. It may be medically reasonable and necessary as part of a comprehensive social history, when you have reason to believe there are unmet SDOH needs that are interfering with the practitioner’s diagnosis and treatment of a condition or illness or will influence choice of treatment plan or plan of care. In these circumstances, patient cost sharing will apply, just as it does for any medical service. The risk assessment wouldn’t usually be administered in advance of the visit.
Example: A patient who hasn’t been seen recently requests an appointment at a specific time or on a specific date due to limited availability of transportation to or from the visit, or requests a refill of refrigerated medication that went bad when the electricity was terminated at their home. If the patient hasn’t gotten an SDOH risk assessment in the past 6 months, you could have the patient fill out an SDOH risk assessment 7–10 days in advance of an appointment as part of intake to ensure that you have enough information to appropriately treat them. You may also furnish SDOH risk assessments as an optional element of the AWV, in which case it’s a preventive service and cost sharing won’t apply.
SDOH risk assessment refers to a review of the individual’s SDOH needs or identified social risk factors
influencing the diagnosis and treatment of medical conditions. Use a standardized, evidence-based SDOH risk assessment tool to assess for:
● Housing insecurity
● Food insecurity
● Transportation needs
● Utility difficulty
G0136 is also added to telehealth services on a permanent basis.
Reference : AMA CPT assistant Bulletin 2023
[…] social determinants of health codes and subcategories will also be […]
[…] support to help the patient cope with the problem(s) addressed in the initiating visit, the SDOH need(s), and adjust daily routines to better meet diagnosis and treatment goals Leveraging lived […]