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No. Coders aren’t involved in screening. Providers typically handle screening, but front desk staff often play a role.

No. Coders aren’t involved in the documentation process, though you often review or clarify documentation after it’s created and apply codes.

Yes. However, your level of involvement may differ based on the EHR system your facility uses. Select Non-EHR or EHR depending on which best describes your facility.

• In an outpatient setting that doesn’t use an EHR, providers document SDOH needs, but coders apply the correct codes.
• Coders must review documented SDOH information to confirm, clarify, or revise codes.
• Get to know providers at your organization. This will help you interpret their documentation and more easily ask them for clarification.

• In an inpatient or outpatient setting that uses an EHR, SDOH data often is already documented. Then:
  • The provider selects the codes when entering the SDOH data.
  • Or the provider documents the SDOH needs, but coders assign codes.
  • Or the EHR uses intelligent mapping to automatically assign codes. This may involve the EHR collecting SDOH from different places into a dashboard, generating a risk score, and triggering a response like a referral.
• Whether codes are assigned by providers, automatically by the EHR, or not at all depends on the EHR and what modules a facility uses. But no matter how your EHR works, coders must review documented SDOH information to confirm, clarify, and revise codes.
• Even if your facility uses an EHR with embedded SDOH codes, you must know what SDOHs the codes represent to make sure coding is correct and supports efforts to address SDOH at your organization and beyond. As a reminder, you can review the SDOH Z codes in Lesson 2.
• Get to know providers at your organization. This will help you interpret their documentation and more easily ask them for clarification.

Not exactly. Coders aren’t directly involved in providing treatment, but you’re responsible for applying procedure codes.

Not exactly. Coders aren’t directly involved in discharging patients. But you assign codes based on provider documentation, which promotes continuity of care if the patient is readmitted or goes to another facility for long-term care or chronic care. You must know how to code SDOH information via Z codes because this information can improve a patient’s continuing care.