SDoH: At the Intersection of Lifestyle and Patient Care

When Social Determinants of Health (SDoH) are clinically relevant, they should be attended to and documented.

One night when I still practiced emergency medicine, I drove a patient home. Z59.6, Low income, and rather than having the department pony up a taxi voucher, I just bundled the patient up into my car at the end of shift and dropped the patient off at home.. My colleagues thought I was off my rocker, but I saw a need and addressed it.

Many institutions have recognized that social determinants of health (SDoH) are very important to attend to because they have profound economic, social, and health implications. It may be financially advantageous to pay the $10 for a cab or dispense medication rather than have a patient readmitted septic because they didn’t fill their antibiotics prescription.

Clinic personnel arranging for transportation so a patient can get to dialysis may save a future emergency department visit for fluid overload and hyperkalemia.

The data on prevalence are not readily available because SDoH are not being documented and coded reliably yet. There is a strong push to remedy this situation, however. One of the solutions has been to allow coding professionals to pull the codes from documentation from individuals other than the healthcare provider caring for the patient. The 2023 ICD-10-CM Official Guidelines for Coding and Reporting have been updated to reflect the SDoH initiative.

Some of our Talk Ten Tuesday listeners have posed some questions which I will address here.

First, the SDoH issue must be clinically significant and relevant to the current encounter. I would posit that being destitute or homeless is always relevant, but the example that is frequently offered is Z60.2, Problems related to living alone. A person who lives alone may be perfectly content and chose that lifestyle. They do not have a problem with living alone. However, an elderly, recently widowed person who has moderate dementia and cannot satisfactorily attend to their activities of daily living or someone who is unable to change a dressing on their back by themselves does have a problem and Z60.2 would be applicable.

From whose documentation can SDoH be derived? If a patient fills out a form, and a provider or another clinician reviews and signs off on it, it is then eligible to be entered into the medical record, and those Z codes are fair game. Clinicians are defined in the guidelines as healthcare professionals who, by regulatory or accreditation requirements or internal hospital policies, are permitted to document “in the patient’s official medical record.” I’m going to defer a discussion of the official medical record for another TalkBack in the future, but let’s leave this at clinicians like social workers, case workers, and nurses for the time being. These individuals are able to document SDoH in their own notes from information provided by the patient or surrogate.

If a provider wants to use SDoH as evidence that the patient is in the moderate risk for the Evaluation and Management level of service determination, however, it is my contention that the provider must make the diagnosis in their own documentation. The crux is whether the diagnosis or treatment was “significantly limited by social determinants of health.” The provider must make that assertion to claim credit for moderate risk.

How should the SDoH be explored? If the clinicians we already mentioned interview the patient and/or caregiver and elicit evidence of issues, if all they do is document them in the legal record, is that sufficient? One might imagine that the best-case scenario is to take action on that information. Ticking a box that a patient is unsheltered homeless might establish Z59.02, but wouldn’t it be preferable for the social worker to contact a shelter and arrange for housing? Similarly, if the emergency physician uncovers a potential health hazard, it would be optimal for them to bring it to someone’s attention who can find a solution for the patient’s plight, as opposed to just documenting it in their note as a limiting factor thereby achieving moderate risk of complications and/or morbidity or mortality of patient management. For the record, I don’t expect everyone to drive patients home at end of shift.

SDoH documentation is at least dual purposed. One goal is to collect epidemiological data and to determine prevalence. The data may support comorbid condition or complication status for certain SDoH which are assessed to increase resource consumption. The other, and probably most important objective, is to improve health and reduce disparities in healthcare for vulnerable populations. We won’t be able to achieve this unless we all start to confront SDoH head on.

For more on SDoH, your providers can take my documentation modules for providers with CME. For one low price, they can access multiple modules on varied documentation topics like excellent and risky documentation practices, how documentation is related to quality and reimbursement, medical necessity, sepsis, and CDI. Have them put MENTATION back into their documentation.

Programming note: Listen to Dr. Erica Remer this morning when she cohosts Talk Ten Tuesdays with Chuck Buck at 10 Eastern.

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Erica Remer, MD, FACEP, CCDS, ACPA-C

Erica Remer, MD, FACEP, CCDS, ACPA-C has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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