Knowledge Base Article

“Social determinants of health (SDOH) refer to the conditions of an individual’s living, learning, and working environments that affect one’s health risks and outcomes. SDOH are now widely recognized as important predictors in clinical care and positive conditions are associated with improved patient outcomes and reduced costs. Conversely worse conditions have been shown to negatively affect outcomes, such as hospital readmissions rates, length of stay, and use of post-acute care but SDOH data collection lacks standardization and reimbursement across clinical settings.”

• Source:   18 / January 2020 Mathew, J, Hodge, C, and Khau, M. Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017. CMS OMH Data Highlight No. 17. Baltimore, MD: CMS Office of Minority Health. 2019.

CMS Office of Minority Health January 2020 Data Highlight

The Office of Minority of Health Data Highlights present national and regional data on health care service, utilization, spending, and quality indicators for the Medicare population. In January of this year, Data Highlight Z Codes Utilization among Medicare Fee-for-Service (FFS) Beneficiaries in 2017 was released.

Z codes Background

• Z codes first became available with the implementation of ICD-10-CM codes in 2015.
• Z codes in categories Z55-Z65 are related to SDOHs.
• Currently there are nine categories of Z codes related to SDOHs available in ICD-10 that encompasses 97 detailed codes (i.e. Category Z59: Problems Related to Housing & Economic Circumstances include 10 codes, two examples being Z590 Homelessness and Z594 Lack of adequate food and safe drinking water).
• Z codes apply to all health settings.

This Data Highlights suggests the following actions “would likely improve the reporting of SDOH coding across care settings:

• Reducing reliance on clinicians to capture SDOH,
• Improving provider and medical code education, and
• Filling gaps in codes.

Study Findings

The authors of this Data Highlight indicate “this study represents the first analysis of Medicare FFS claims data for the utilization of Z-codes.” Following are a few key findings from the analysis of claims with Z codes in 2017:

• Z-codes were present in approximately 1.4% of 33.7 million claims,
• Of the 467,136 Z-codes claims, 35% of the beneficiaries were under the age of 65,
• Z590 Homelessness was the only Z code with higher utilization in males than females, and
• Significant disparities were observed among blacks, Hispanics and American Indians/Alaska Natives for codes Z590 Homelessness.

Data Highlight Conclusion: Lack of Awareness and Confusion

In addition to the analysis of claims, CMS held a listening session to better understand the low use of Z codes. “Participants noted a general lack of awareness of the Z codes, and a confusion as to who could document social needs. Several of the participants were unaware that the FY 2019 ICD-10-CM Official Guidelines for Coding and Reporting stated that clinicians other than the patient’s provider could document social determinants of health. This would include but not be limited to nurses, social workers, psychologists, and dieticians.”

RealTime Medicare Data (RTMD) Findings for Alabama, Georgia and Tennessee

After reading this highlight I turned to our sister company to search the data for SDOH Z code usage. The following two tables highlight the volume of claims which included a Z code in the inpatient and outpatient setting for CMS Fiscal Year (FY) 2018 and 2019 in Alabama, Georgia and Tennessee.

RTMD claims data mirrors the Data Highlight in that there is definitely opportunity for improvement.

Moving Forward

Is there a lack of awareness about SDOHs and the related ICD-10-CM Z codes at your facility? If so, potential key stakeholders that need to be educated could include Physicians, Nurses, Social Workers, Case Management, Dieticians and CDI Specialists.

Following are a few available resources about SDOH available to provide education:

• CDC’s Social Determinants of Health: Know What Affects Health webpage at https://www.cdc.gov/socialdeterminants/,
• American Hospital Association’s SDOH Fact Sheet at https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf,
• American Hospital Association’s Social Determinants of Health webpage at https://www.aha.org/social-determinants-health/populationcommunity-health/community-partnerships,
• April 16, 2019 CMS Blog: Actively Addressing Social Determinants of Health will Help Us Achieve Health Equity at https://www.cms.gov/blog/actively-addressing-social-determinants-health-will-help-us-achieve-health-equity
• This CMS blog includes links to some existing tools available to address identifying a patient’s needs.
• Coding Clinic advice is available in the following quarters:
• First Quarter 2018: Page 18,
• Fourth Quarter 2019: Page 66, and
• Fourth Quarter 2019: Page 67.