Author: Arlene Baril
Senior Physician Auditor and Educator

(303) 801-0111


What are SDOH?

Per the World Health Organization (WHO) definition, “Social Determinants of Health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks”.

SDOH can be grouped into five (5) domains:

  1. Economic stability
  2. Education access and quality
  3. Healthcare access and quality
  4. Neighborhood & built environment
  5. Social & community context

The SDOH have an important influence on health inequities – the unfair and avoidable differences in health status seen within and between countries. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health.

The following list provides examples of the social determinants of health, which can influence health equity in both positive and negative ways:

  • Income and social protection
  • Education
  • Unemployment and job insecurity
  • Working life conditions
  • Food insecurity
  • Housing, basic amenities and the environment
  • Early childhood development
  • Social inclusion and non-discrimination
  • Structural conflict
  • Access to affordable health services of decent quality.

Research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDOH account for between 30-55% of health outcomes. In addition, estimates show that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector.

Acknowledgment of the influence that SDOH have on patients’ outcomes is growing, as is the desire to incorporate SDOH into patient-care plans.  These codes allow physicians, hospitals, health systems and payers to better track patient needs and identify solutions to improve the health of communities.  A good example is the Healthy People 2030 initiative, developed by the Health Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2030.  Details can be found here:  https://health.gov/healthypeople

Physicians have had the ability to document SDOH since ICD-10 was adopted in 2015, however reporting these elements in the medical record or on a claim had little emphasis as to their impact or requirements for reporting prior to January 7, 2021.  On that date, guidance was issued by Centers for Medicare & Medicaid Services (CMS) to state health officials and was designed to drive the adoption of strategies that address the SDOH in Medicaid and the Children’s Health Insurance Program (CHIP).  The goal of this guidance is to assist states to further improve beneficiary health outcomes, reduce health disparities, and lower overall costs in Medicaid and CHIP.

CMS continues to be committed to accelerating the industry’s shift away from traditional fee-for-service payment models.  There are broad reaching initiatives to promote more providers to embrace value-based models which hold clinicians and the reporting entities accountable for health care costs and improving patient care quality to foster better patient outcomes and long-term healthcare cost savings.   To view the opportunities in Medicaid and CHIP to address SDOH, please visit: https://www.medicaid.gov/federal-policy-guidance/downloads/sho21001.pdf.

Codes continue to be added to SDOH categories.  Per the Official Coding Guidelines, Section 1.B.14-code assignment for the SDOH codes may be based on medical record documentation from clinicians who are not the patient’s provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient’s diagnosis). In this context, “clinicians” other than the patient’s provider refer to healthcare professionals permitted, based on regulatory or accreditation requirements or internal hospital policies, to document in a patient’s official medical record.  This also includes patient’s self-reported information if it is signed off and incorporated into the health record by either a clinician or provider. (refer to AHA Coding Clinic for ICD-10-CM/PCS, fourth Quarter 2019, page 66).

The 2023 ICD-10-CM April Addenda update includes a number of revisions to the SDOH codes found in Chapter 21.  There was a total of 13 new codes, 7 deleted codes and 1 revised code in Chapter 21. The addendum detail can be found here:  https://www.cms.gov/medicare/icd-10/2023-icd-10-cm

Per the 2024 IPPS proposed rule Fact Sheet that was released on 4/10/23-SDOH Diagnosis Codes:

“IPPS payment is made based on the use of hospital resources in the treatment of a patient’s severity of illness, complexity of service, and / or consumption of resources. Generally, a higher severity level designation of a diagnosis code results in a higher payment to reflect the increased hospital resource use. After review of our data analysis of the impact on resource use generated using claims data, CMS is proposing to change the severity designation of the three (3) ICD-10-CM diagnosis codes describing homelessness (e.g., unspecified, sheltered, and unsheltered) from non-complication or comorbidity (NonCC) to complication or comorbidity (CC), based on the higher average resource costs of cases with these diagnosis codes compared to similar cases without these codes”.  This can affect future MS-DRG assignments.  The draft proposed rule can be found here:  https://public-inspection.federalregister.gov/2023-07389.pdf

The ICD-10-CM codes for SDOH can be found in categories Z55-Z65.

Z55 – Problems related to education and literacy: This code can apply in cases where a patient is illiterate, or schooling is unavailable. It can also apply in cases where a patient is underachieving in school, has not achieved a high school level of education, or has an educational maladjustment.

Z56 – Problems related to employment and unemployment: This code relates to patients who are unemployed or those who have recently changed jobs. It can also apply to those who currently face the threat of job loss or have a stressful work schedule. And to patients who have discord with their so-workers or have an unpleasant work environment, including sexual harassment.

Z57 – Occupational exposure to risk: This code applies to patients with occupational exposure to noise, radiation, dust, environmental tobacco smoke, toxic agents, or exposure to extreme temperatures.

Z58 – Problems related to physical environment: This code applies to patients with inadequate drinking water.

Z59 – Problems related to housing and economic circumstances: This code may be suitable for homeless patients, those residing on the street, or those living in a residential institution. This code can also apply to those with food insecurity, low income, or insufficient social insurance or welfare support.

 Z60 – Problems related to social environment: This code may be appropriate for patients with adverse effects from living alone or those who have trouble adjusting to life-cycle transitions. This code can also apply to those with acculturation difficulty leading to social exclusion, rejection, or targeted discrimination.

 Z62 – Problems related to upbringing: This code relates to patients with parent or sibling conflicts, including parental overprotection or hostility, inappropriate or excessive pressure, or a history of abuse or neglect in childhood. This code can also apply to patients with inadequate parental supervision, those in child welfare custody, or those with an institutional upbringing.

Z63 – Other problems related to primary support group, including family circumstances: This code can be used for patients with disappearances or death in the family or other stressful life events affecting family and household – including family members deployed to the military. This code can also apply to patients who provide home care for an ailing relative. Or those who have family stress due to alcoholism or drug addiction in the family.

Z64 – Problems related to certain psychosocial circumstances: This code may be appropriate for patients with an unwanted pregnancy, multiparity, or discord with counselors.

Z65 – Problems related to other psychosocial circumstances: This code relates to patients with convictions in civil and criminal proceedings (with or without imprisonment), imprisonment, or other legal circumstances. This code can also apply to patients who have been victims of crimes or terrorism. And those who have had exposure to disaster, war, and other hostilities.

Collection of the data can be done electronically, within the EMR, via a hard copy form or a hybrid model.  Pinnacle has identified several official source job aids, template tools and diagrams to assist providers in the implementation to capture SDOH in their practices and facilities.  While there are many available, below are some from official sources, such as the Centers for Medicare and Medicaid Services, or produced in collaboration with CMS.  Below are examples that our readers might find particularly helpful:

American Hospital Association (AHA) guidance document on ICD-10-CM coding of SDOH:

https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf

American Academy of Family Physicians SDOH toolkit:

https://www.aafp.org/family-physician/patient-care/the-everyone-project/toolkit.html

CMS-The Accountable Health Communities Health Related Social Needs Screening Tool:

https://innovation.cms.gov/files/worksheets/ahcm-screeningtool.pdf

As SDOH reporting continues to be refined, more data will be forthcoming. For more information, please contact Arlene Baril at ABaril@AskPHC.com or 720-640-2616.