AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2019 Issue 4; Ask the Editor

Patient Self-Reported Information and Social Determinants of Health Codes

Is it appropriate to utilize patient self-reported documentation to assign codes for social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances? Currently, the ICD-10-CM Official Guidelines for Coding and Reporting allows code assignment 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. ...

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