AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2019 Issue 4; Ask the Editor
Patient Self-Reported Information and Social Determinants of Health Codes
Is it appropriate to utilize patient self-reported documentation to assign codes for social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances? Currently, the ICD-10-CM Official Guidelines for Coding and Reporting allows code assignment 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. ...
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Article Overview
This premium article discusses whether patient self-reported information can support coding for social determinants of health when that information is documented in the medical record by a clinician or provider. It is aimed at coding professionals, CDI staff, and other healthcare documentation specialists who need to understand the documentation source requirements and the broader ICD-10-CM guidance involved.
Why This Topic Matters
Accurate capture of social determinants of health can affect data quality, risk capture, and documentation consistency across the medical record. This article helps readers understand the general documentation framework used when evaluating whether such information may support ICD-10-CM code assignment.
What You Will Learn
- How social determinants of health information is discussed in ICD-10-CM coding guidance
- What types of documentation sources are addressed in the article
- How patient-reported information is treated in the context of the health record
- Why documentation incorporation into the record matters for coding review
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation integrity specialists
- Healthcare providers
- Revenue cycle professionals
Code Ranges Discussed
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