In case you missed it, ICD-10 updates come twice a year now. April 1, 2023 brings us our first official mid-year update and while there are not as many new codes as we typically see in October, there are more updates than we’ve seen in previous years when April updates were meant for the urgent release of codes related to new technologies. This spring, we will see new ICD-10-CM guidelines and codes related to social determinants of health and abuse.

It is important to make note of these new codes, since they largely represent factors we haven’t traditionally looked for in medical record documentation in the past. These are not elements of coding that we are used to capturing, so it is essential to be aware of the codes’ existence so you can assign them when documented.

You can download the latest ICD-10-CM code sets, addenda, and guidelines on CMS’ website, but this blog post will cover the major changes to get you ready for April 1.  If you use a codebook, it is important to note that the guidelines have been updated again since October. We recommend that you always keep an electronic copy of the most recent guidelines.  Encoder software should be updated before or on April 1. Contact your software vendor if you have any questions about the availability of the April update.

Social Determinants of Health

Guideline Change

Changes to the social determinants of health (SDOH) guidelines and codes have been rampant over the last couple of years. In October, the guidelines were amended to include a statement that SDOH codes should only be assigned when the provider indicates their clinical significance. This seemed to contradict another statement in the guidelines about coding SDOH whenever they are documented. For April, the guideline has been tweaked again to provide more clarity. In essence, the guideline states that SDOH codes are assigned when documented and they are significant and specific examples are given.

The newly worded guideline I.C.21.c.17. is noted below with changes in bold type.

Social determinants of health (SDOH) codes describing social problems, conditions, or risk factors that influence a patient’s health should be assigned when this information is documented in the patient’s medical record. Assign as many SDOH codes as are necessary to describe all of the social problems, conditions, or risk factors documented during the current episode of care. For example, a patient who lives alone may suffer an acute injury temporarily impacting their ability to perform routine activities of daily living.

When documented as such, this would support assignment of code Z60.2, Problems related to living alone. However, merely living alone, without documentation of a risk or unmet need for assistance at home, would not support assignment of code Z60.2. Documentation by a clinician (or patient-reported information that is signed off by a clinician) that the patient expressed concerns with access and availability of food would support assignment of code Z59.41, Food insecurity. Similarly, medical record documentation indicating the patient is homeless would support assignment of a code from subcategory Z59.0-, Homelessness.

For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider since this information represents social information, rather than medical diagnoses. For example, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record.

Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider.

New SDOH Codes

Several new SDOH codes are being added along with inclusion terms to assist the coder in knowing when to use them.

New codes are being added for problems related to health literacy, which can be used to report patients who have difficulty understanding their medical condition or medication instructions. The codes for problems related to physical environment and inadequate housing have been expanded to provide more granularity in reporting.

Changes to SDOH Code Titles, Inclusion Terms, and Excludes Notes

Be on the lookout for new Excludes2 notes for code Z59.81 (Housing instability, housed), indicating that additional codes for extreme poverty, financial insecurity, low income, and other material hardship due to limited financial resources may be used with this code.

The description for code Z59.87 (Material hardship) has been changed to “Material hardship due to limited financial resources, NEC” and the inclusion terms have also been expanded in a similar manner.

A new inclusion term has been added to code Z60.4 (Social exclusion and rejection) for “social isolation.”

Patient Noncompliance

In October, the noncompliance codes were expanded to include caregiver noncompliance and include the reason for patient noncompliance. In concert with this change, code Z91.14 is being expanded to report the reason for noncompliance:

Adult and Child Abuse

New Codes for Psychological and Financial Abuse

New codes have been added to report psychological and financial abuse. Financial abuse is a method of gaining power or control by limiting access to the victim’s assets. It is a common ploy in domestic abuse and victims commonly cite it as the reason they stayed with or returned to an abusive partner.

As with existing abuse codes, the new abuse codes distinguish between confirmed and suspected abuse. The codes for financial abuse specify the victim as either an adult or child. For example, a child actor whose parent has control over their financial assets and uses that control in an abusive manner would be reported with code T74.A2.

History of Abuse

Similarly, new codes have been added to report history of abuse.

New Perpetrator Codes

In alignment with the new abuse codes, the perpetrator codes are also being expanded. The codes for spouse as the perpetrator of abuse are being expanded to specify whether the spouse is current or former. Codes for male, female, and nonbinary partner are also being added to include intimate or dating partners who commit abuse.

Code Y07.4 (Other family member, perpetrator of maltreatment and neglect) has also been extended to specify the family member committing abuse. These new codes have several inclusion terms to help coders assign the correct code.

And finally, code Y07.54 (Acquaintance or friend, perpetrator of maltreatment and neglect) has been added to allow for reporting abuse committed by a non-family member who is an acquaintance of the victim.

Guideline Review

With the expansion of the abuse and perpetrator codes, it’s worth reviewing the guidelines for adult and child abuse. Guideline I.C.19.f. states:

Sequence first the appropriate code from categories T74, Adult and child abuse, neglect and other maltreatment, confirmed, or T76, Adult and child abuse, neglect and other maltreatment, suspected, for abuse, neglect and other maltreatment, followed by any accompanying mental health or injury code(s).

If the documentation in the medical record states abuse or neglect, it is coded as confirmed (T74.-). It is coded as suspected if it is documented as suspected (T76.-).

For cases of confirmed abuse or neglect an external cause code from the assault section (X92-Y09) should be added to identify the cause of any physical injuries. A perpetrator code (Y07) should be added when the perpetrator of the abuse is known. For suspected cases of abuse or neglect, do not report external cause or perpetrator code.

If a suspected case of abuse, neglect or mistreatment is ruled out during an encounter code Z04.71, Encounter for examination and observation following alleged physical adult abuse, ruled out, or code Z04.72, Encounter for examination and observation following alleged child physical abuse, ruled out, should be used, not a code from T76.

If a suspected case of alleged rape or sexual abuse is ruled out during an encounter code Z04.41, Encounter for examination and observation following alleged adult rape or code Z04.42, Encounter for examination and observation following alleged child rape, should be used, not a code from T76.

If a suspected case of forced sexual exploitation or forced labor exploitation is ruled out during an encounter, code Z04.81, Encounter for examination and observation of victim following forced sexual exploitation, or code Z04.82, Encounter for examination and observation of victim following forced labor exploitation, should be used, not a code from T76.

BOLO for New Documentation Elements

While a cursory glance of the new codes seems to reveal nonessential information, the focus on SDOH and abuse data is becoming increasingly important. It’s easy to gloss over the new codes without really digesting their meaning or impact to reported health data. Be sure to keep up with our training programs and blog posts to help you be on the lookout (BOLO) for important changes!

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