Scott D. Duncan, MD, MHA

There has been an increased emphasis on the social determinants of health in recent years. Conditions found in the places where people live, learn, work, and play affect health and quality of life, increasing risk and adversely altering outcomes. Consider the following common scenario:

“A neonatologist is called to assume care of a newborn infant on DOL 1. The infant is exhibiting jitteriness and irritability. The maternal history is significant for a family history of alcoholism and domestic violence. The mother ran away from home at 15 and currently lives in a homeless camp. She admits to using marijuana, methamphetamine, and heroin. Finnegan scoring is initiated, and scores of 10, 12 & 12 are recorded. The infant is admitted with cardiorespiratory monitoring and begun on oral morphine.”

The astute practitioner is aware of health inequities and their effects on our patients and families. In the above vignette, we see issues related to socioeconomic status, abuse, education, housing, food security, employment, family support, and access to health care. The AAP News (January 2021, Coding Corner) published an article titled “Use ICD-10-CM codes when the social determinant of health identified.” Here is a partial list of the social determinants of health (SODH): 

• Abuse (History of) 
• Economic difficulties 
• Education 
• Environmentally compromised housing 
• Family support group issues 
• Food insecurity 
• Housing issues 
• Nutrition 
• Parent/sibling child issues 
• Social issues 
• Substance use 
• Transportation difficulty 
• Upbringing issues 

While the associated ICD-10 codes may or may not be used in the NICU, they may impact Neonatal Follow Up. Identification of one or more SDOHs that constrains diagnosis or treatment options increases “risk” and may impact the Current Procedural Terminology (CPT®) evaluation and management (E/M) code. The physician needs to document these issues when they influence the encounter and place the proper ICD-10 codes when documenting in the medical record. 

Coding for SDOH may be based on medical record documentation from ancillary providers, as this information is categorized as social information and not diagnosis. Alternatively, the information may be provided by the patient and/or caregiver, with inclusion into the medical record. Below are the broad categories of Z codes that might be used in such an encounter: 

• Z55 Problems related to education and literacy 
• Z57 Occupational exposure to risk factors 
• Z59 Problems related to housing and economic circumstances 
• Z60 Problems related to the social environment 
• Z62 Problems related to upbringing 
• Z63 Other problems related to the primary support group, including family circumstances 
• Z71 Persons encountering health services for other counseling and medical advice, not elsewhere classified 
• Z77 Other contacts with and (suspected) exposures hazardous to health 

Consider the following scenario: 

“A NICU graduate is being seen in Neonatal Follow Up with poor weight gain, despite being fed a hypercaloric formula. In filling out a risk assessment, the mother notes a lack of transportation and is recently separated and divorced. The mother states she has a prescription for formula and qualifies for WIC; however, she relies on a “friend” to get her to the WIC office.” 

The limited access to free formula and unreliable means of transportation to get the formula places this patient at a high risk of treatment failure due to the food shortage in the home. Appropriate ICD-10 coding would include: 

• Z59.6 Low income 
• Z63.5 Disruption of the family by separation and divorce 
• Z59.4 Lack of adequate food 

There are CPT® codes related to standardized assessment of the SDOH, whether patient-focused or caregiver-focused.If a standard instrument determines SDOH risk factors, CPT® codes include: 

• 96160 Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument 
• 96161 Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument 

If SDOH risk factors are determined during an E/M service via a non-standardized tool, the determination of SDOH is included in the E/M service. As previously noted, adverse SDOH may impact risk within medical decision making and/or time as related to office CPT® E/M codes, resulting in a higher level E/M code selection. Beyond the revenue impact of a specific E/M encounter, reporting of SDOH codes may affect risk-adjusted and/or value-based payment initiatives. The recognition of the adverse effects of SDOH on the patient experience will likely result in an impact on care delivery and future reimbursement. 

Emma Lazarus was a Jewish Sephardi Portuguese American poet who penned a sonnet titled the New Colossus, which compares the Statue of Liberty to the ancient Greek Colossus of Rhodes, which is one of the Seven Wonders of the Ancient World. She wrote the poem in 1883 to raise money to construct the pedestal for the Statue of Liberty. In his musical Miss Liberty, Irving Berlin used the final stanza as the basis for a song, and Joan Baez used part of the poem in writing lyrics to some of her compositions. 

She states in the poem: 

“Give me your tired, your poor, your huddled masses yearning to breathe free, the wretched refuse of your teeming shore. Send these, the homeless tempest-tost to me, I lift my lamp beside the golden door!” 

As healthcare providers, we are the lamp and are tasked with recognizing the vulnerable and reducing disparities in our healthcare delivery system.

For more information on coding for the social determinants of health, go to https://downloads.aap.org/AAP/PDF/SDOH.pdf

Disclosure: The author has no disclosures.