This page addresses follow-up questions and additional information pertinent to our webinar
Social Determinants of Health: Coding Beyond the Diagnosis.

** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: Can SDOH codes be assigned from nursing or social work documentation?
A: YES! ICD-10-CM guideline I.C.21.c.17. states code assignment CAN be made based on documentation from other clinicians. Guideline I.B.14. defines other clinicians as any healthcare professional that is permitted to document in a patient’s medical record based on regulatory requirements, accreditation, and/or internal hospital policies. These requirements may vary based on state and organizational policies.

Some examples of other clinicians who may meet these requirements are social workers, community health workers, case managers, and nurses. Check your individual state and organizational polices and procedures to ensure compliance.

Q: Can I code SDOH if it doesn’t affect treatment?
A: No. ICD-10-CM guideline I.C.21.c.17. states there must be a documented risk or unmet need for assistance to assign a SDOH code.
Documentation of patient concerns with food access or a patient experiencing homelessness would support assignment of the appropriate SDOH code. Food insecurity and homelessness are risk factors that will directly affect health outcomes if patient assistance is not provided.

Documentation of a patient living alone would not support assignment of a SDOH code. Many individuals live alone with no associated risk to their health.

However, if there is documentation of an associated risk or need for assistance a SDOH code should be assigned. For example, if a patient who lives alone has an acute fracture which temporarily prevents them from performing daily activities, a SDOH identifying problems related to living alone should be assigned.

Q: Can I assign an ICD-10-CM code for SDOH from patient self-reported information?
A: Yes! ICD-10-CM guideline I.C.21.c.17. states patient self-reported information CAN be used to assign SDOH codes; However, this information must be signed by the patient’s provider or another clinician.

For example, a SDOH cannot be assigned from an unsigned patient questionnaire that notes food insecurity.

However, if the same questionnaire is signed by the patient’s provider or another clinician and entered into the patient’s official medical record, a SDOH code identifying food insecurity CAN be assigned.