Social Determinants of Health

Author: Keisha Wilson CCS, CPC, CRC, CPB, CPMA, AAPC Approved Instructor

Social determinants of health (SDOH) are defined as economic and social conditions that influence the health of people and communities. Examples may include food, housing insecurity, education and employment. These conditions tend to have the most critical impact on people’s health, well-being, and quality of life. The American Academy of Family Physicians (AAFP)  and CMS list other socioeconomic situations, such as:

  • Z55 – Problems related to education and literacy
  • Z56 – Problems related to employment and unemployment
  • Z57 – Occupational exposure to risk factors
  • Z58 – Problems related to the physical environment
  • Z59 – Problems related to housing and economic circumstances
  • Z60 – Problems related to the social environment
  • Z62 – Problems related to upbringing
  • Z63 – Other problems related to a primary support group, including family circumstances
  • Z64 – Problems related to certain psychosocial circumstances
  • Z65 – Problems related to other psychosocial circumstances

SDOH is a ripple effect that contributes to a wide range of health disparities and inequities among patients when not addressed. For example, people who don’t have access to grocery stores with healthy foods and transportation are less likely to have good nutrition. That raises their risk of chronic health conditions and diseases such as heart disease, diabetes, obesity, high cholesterol, and kidney disease.  SDOH can also lead to an increase in mortality, but if identified and managed by early intervention, providers and their care teams can lower patients’ mortality rates.

Documentation & Diagnosis coding

For 2021 & 2023 Evaluation and Management code and guideline changes, SDOH on the revised table of risk falls under – Complications and/or Morbidity or Mortality of Patient Management at the moderate level if using MDM “Diagnosis of treatment significantly limited by social determinants of health”.  For example, a patient who recently lost their job due to the recession now has no health coverage and cannot afford insurance; this patient has not taken the medication for their chronic heart disease and has come into the office with an exacerbated condition. A few SDOHs are affecting this patient, and the provider will need to get others involved on the care team to address the disparities, make referrals and, depending on the patient’s condition, might require an Emergency Department visit or admission to the hospital.

Per AMA, risk is “the probability and/or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor, self-limited adverse effect of treatment may be low risk. Definitions of risk are based upon the usual behavior and thought processes of a physician or other qualified health care professional in the same specialty”.

When using total time, providers will want to include the face-to-face and non-face-to-face time it took on the service date to address a patient’s SDOH needs. Providers and care team members can obtain information from the patient and caregivers. Patient self-reported documentation may be used to assign codes for social determinants of health information obtained is signed off by and incorporated into the medical record by either a clinician or provider.

Documentation continues to play a crucial role in identifying and combating SDOH needs that affect their patient population.  Providers should report the conditions by utilizing the ICD-10-CM codes Z55-Z65 (“Z codes”) found in Chapter 21 (Z00-Z99, Factors influencing health status and contact with health services).   These codes help identify the insurance companies’ nonmedical factors that may affect a patient’s health status. In the last few years, the nation has seen experienced a series of traumatizing events, from a pandemic and public health emergency to an impending recession.  Millions of people all over the United States have been and will be affected.

For FY 2022, the AMA added 159 new SDOH diagnosis codes, which shows how much social disparities have affected the patients and the need for improvement, change and reporting of the codes.  In FY2023, 3 new codes were added:

  • Z59.82 transportation insecurity
  • Z59.86 Financial insecurity
  • Z59.87 Material hardship

Coders will want to review the ICD-10 CM guidelines and the “inclusion terms” for reporting the diagnosis codes.  CMS 1500 form allows providers to select 12 diagnosis codes to register.  Providers and coders can choose as many SDOH codes as are needed to describe risk factors affecting the patients. Per ICD-10CM 2023 Guidelines “Assign as many SDOH codes as are necessary to describe all of the problems or risk factors. These codes should be assigned only when the documentation specifies that the patient has an associated problem or risk factor. For example, not every individual living alone would be assigned code Z60.2, Problems related to living alone”.

EHR & Screening Tools

Some may find it time-consuming to document more information and select additional codes, but many EHRs (Electronic Health Records) have made it easier for providers to choose the codes.  Any “clinician” or person part of the care team, such as social workers, case managers, nurses, community health workers, providers, nurse practitioners, and physician assistants, can collect SDOH from the time of intake until the health assessment.  Many organizations now have screening tools embedded into their EHR.  Alternatively, some may have a checklist on paper that is filled out and scanned into the EHR after. 

Per the American Hospital Association (AHA), “robust social needs data is critical to hospitals’ efforts to improve the health of their patients and communities. And employing a standardized approach to screening for, documenting and coding social needs will enable hospitals to”:

  • Track the social needs that impact their patients, allowing for personalized care that addresses patients’ medical and non-medical needs
  • Aggregate data across patients to determine how to focus a social determinants strategy; and
  • Identify population health trends and guide community partnerships

What are Agencies Doing?

Many agencies such as CMS, HHS, and other private and commercial payers focus on improving SDOH across all states.  CMS’s roadmap to combating SDOH states that the new guidance was released in 2021; acknowledges that an understanding of the social, economic, and environmental factors that affect the health outcomes of Medicaid and CHIP populations can be an integral component of states’ efforts to realign incentives, reduce costs, and advance value-based care in their health systems.  CMS has emphasized addressing SDOH across all its programs in its continued efforts to move toward a value-based care delivery model”. 

Many public advocates are looking to public health organizations, their partners, and stakeholders in education, transportation, and housing to take action to improve the conditions in people’s environments. 

There are “Five Health Equity Priorities for Reducing Disparities in Health”. The priorities will help inform CMS’s efforts over the next decade on how to make each a priority in achieving and eliminating health disparities.  The framework reinforces the ongoing attention needed to address avoidable inequalities and eliminate health and health care disparities”.

  • Priority 1: Expand the Collection, Reporting, and Analysis of Standardized Data
  • Priority 2: Assess Causes of Disparities Within CMS Programs and Address Inequities in Policies and Operations to Close Gaps
  • Priority 3: Build the Capacity of Health Care Organizations and the Workforce to Reduce Health and Health Care Disparities
  • Priority 4: Advance Language Access, Health Literacy, and the Provision of Culturally Tailored Services
  • Priority 5: Increase All Forms of Accessibility to Health Care Services and Coverage

Documenting these conditions alone won’t be enough for providers.  Reducing SDOH will take a team approach, from documenting, coding, referrals and being proactive in patient care.  EHRs should have the necessary questionaries and surveys to capture and report the conditions.  The continued effort of the insurance companies to give patients coverage and pay for programs such as nutritional counselling to better their health. It will also take the steps of public health organizations and their partners in sectors like education, transportation, and housing, a call to improve the conditions in people’s environments that will foster the necessary change. 

If you would like to schedule training for your organization or private practice providers or schedule a chart review email us today at or visit the website and fill out the “contact us” form.


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