How Can Coders Support ICD-10-CM Coding for SDOH?
- Base coding choices on the providers’ documentation and the patient’s self-reported data, as long as a provider signs off on the patient’s self-reported data and includes it in the medical record.
- Review a patient’s medical record to find documentation in support of the correct ICD-10-CM diagnosis codes, including codes in categories Z55-Z65.
Coders and providers must work together to make sure clear, consistent documentation supports specific SDOH Z codes.