Q&A: Integrating SDOH documentation

Q: What are the benefits of integrating social determinants of health (SDOH) documentation into behavioral health coding?

Leigh Poland, RHIA, CCS, CDIP, CIC: Over the last several years, there's been more and more emphasis on encouraging facilities and physicians to track, trend, and assess for SDOHs. We have very robust ICD-10-CM codes that can help us capture any SDOH factors: Z55- Z65.

These Z codes are not for diseases or injuries, but for circumstances, allowing for a more complete picture of the patient's health. The documentation can come from nonphysicians, such as clinicians, nurses, social workers, and case managers. They should document relevant SDOH information from their interactions or health risk assessment. We need to be able to capture this documentation in order to assign these particular codes. Ideally, we're integrating this assessment/documentation into the electronic health record so, in turn, we can capture the codes.

Why is this important? It paints a holistic picture of that patient. It gives a comprehensive understanding of the patient's overall health. It improves resource allocation. If we help to identify the social factors that are impacting that patient, we can link them with resources that will help support their social risk factor. This is beyond traditional medical services, and it enables better allocation of resources.

It allows for informed public health strategy because we have that aggregated data on SDOHs, and then it also allows payers and policymakers to better understand the impact of SDOHs on health outcomes and resource allocation.

Editor’s note: Poland provided this information in the HCPro webinar, “Mind the Gap: Strengthening Behavioral Health Coding and Documentation.”