AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Issue 1; Ask the Editor
Coding of Social Determinants Using Non-Physician Documentation
Is it appropriate to utilize nonphysician documentation to assign codes that provide information on social determinants of health? For example, codes from categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, provide important information that is typically only found in nurses or social worker documentation. ...
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Article Overview
This premium article explores the use of non-physician documentation, such as notes from nurses or social workers, for coding social determinants of health. It is relevant to coders, clinical documentation staff, compliance professionals, and revenue cycle teams who need a clearer understanding of how social risk information is captured in diagnosis coding and the broader documentation context surrounding it.
Why This Topic Matters
Social determinants of health are often documented outside the physician record, so teams need to know what types of source documentation may support accurate coding and compliant record abstraction. The article helps readers understand the documentation context and coding scope involved in social and socioeconomic risk information.
What You Will Learn
- How social determinants of health are documented in the record
- What kinds of non-physician documentation may be relevant to coding questions
- How social and socioeconomic risk information is framed in diagnosis coding
- Why documentation source matters for capturing social risk information
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation integrity specialists
- Compliance professionals
- Revenue cycle staff
Codes Discussed
Code Ranges Discussed
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