Did You Know? AHA Says Nonphysician Documentation Supports Z55-Z65

Thu, Jul 26, 2018 --

Compliance, ICD-10

documentation of social determinants for ICD-10 coding

Reporting ICD-10-CM social information codes (Z55-Z65) based on documentation from nonphysicians is OK, according to official guidelines from the AHA. Before you change your approach to coding, here are the facts.

Locate the Original Coding Clinic® Q&A

In early 2018, AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS (vol. 5, no. 1) published an answer to the question of whether you may use nonphysician documentation to assign codes that give information about social determinants of health. The example given was Z55-Z65 (Persons with potential health hazards related to socioeconomic and psychosocial circumstances).

The published response was that because the codes are about social information, not medical diagnoses, it is OK to assign the codes based on the documentation of other clinicians involved in patient care.

Dig Deeper With Special Post From AHA

More recently, the AHA provided a more extensive explanation, posted on its social determinants resource page.

The first question you may have is what is a social determinant of health, and the AHA post lists these examples:

  • Education
  • Employment
  • Food
  • Health behaviors
  • Housing
  • Social support
  • Transportation
  • Violence.

They are all social, economic, and environmental factors that may influence health outcomes.

Here’s More Information on Why and Who

The AHA post reports that codes Z55-Z65 aren’t reported often in the inpatient setting, with the exception of discharges for mental health and alcohol/substance use. One possible cause identified was that the ICD-10-CM Official Guidelines generally require physician documentation to support coding, but social determinants are often recorded by case managers, discharge planners, social workers, and nurses.

So, effective Feb. 18, 2018, you may use documentation by “all clinicians involved in the care of the patient” to support Z55-Z65 coding. You should see the change included in the next update to the Official Guidelines, too.

The AHA post indicates that collecting this sort of social determinant data will help hospitals and health systems track patient needs and come up with more targeted solutions to improve health in their communities.

What About You?

Do you think this change will encourage additional reporting of ICD-10-CM social determinant codes Z55-Z65? Or do you think there’s another reason these codes often go unreported?



Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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