Knowledge Base Article

Over the past thirteen years, part of my job has been to review medical records. When thinking about Social Determinants of Health (SDOHs), I distinctly remember one project where I reviewed three separate admissions for the same patient. Digging into the charts, I noted the patient’s discharge status was consistently to “tent city.” Unfortunately, tent cities are not a phenomenon limited to the Southeastern United States. Also unfortunately, this is a perfect example of a SDOH that can negatively impact an individual’s health outcomes.

Did You Know?

Social Determinants of Health (SDOHs) and Z Codes

Z codes first became available with the implementation of ICD-10-CM codes on October 1, 2015. Z code categories Z55 – Z65 are related to SDOHs. Eleven new codes became effective on October 1, 2021, bringing the list to a total of 109 codes.

New FY 2022 SDOH Z codes

• Z55.5 – Less than a high school diploma,
• Z58.6 – Inadequate drinking-water supply,
• Z59.00 – Homelessness unspecified,
• Z59.01 – Sheltered homelessness,
• Z59.02 – Unsheltered homelessness,
• Z59.41 – Food insecurity,
• Z59.48 – Other specified lack of food,
• Z59.811 – Housing instability, housed, with risk of homelessness,
• Z59.812 – Housing instability, housed, homelessness in past 12 months,
• Z59.819 – Housing instability, housed unspecified, and
• Z59.89 – Other problems related to housing and economic circumstances.

In January 2020, the CMS published an initial Data Highlight focused on the utilization of Z codes among Medicare Fee-for-Service Beneficiaries in 2017 (link). The authors suggested that “reducing reliance on clinicians to capture SDOH, improving provider and medical coder education, and filling gaps in codes, among other policy-based interventions, would likely improve the reporting of SDOH coding across care settings.”

In September 2021, the CMS published a follow-up Data Highlight titled, Utilization of Z Codes for Social Determinants of Health among Medicare Fee-for-Service Beneficiaries, 2019 (link).

September 2021 Data Highlight Key Findings

Barriers to increasing documentation of Z codes

• Z code claims are not generally used for payment purposes,
• There are a limited number of Z codes and sub-codes meaning some social, economic, and environmental determinants may not be captured,
• While there are providers who may have had training regarding SDOH and recognize challenges some of their patient’s face, “they may feel limited in what they can do and/or may require guidance on how best to assist patients in addressing their non-medical needs.”

Data Highlight Authors Conclusions

• “More widely adopted and consistent documentation of them is needed to comprehensively identify non-medical factors affecting health and to track progress toward addressing them; doing so could aid in work toward achieving health equity and ensuring highest quality and best-value care for all beneficiaries.”
• “It will be critically important to carefully analyze data from 2020 and 2021 to understand whether and to what extent the public health emergency (PHE) may have had an impact on social, economic, and environmental determinants, and/or the rate of documentation of those determinants via Z codes.”
• “All members of the US health system: payers, patient-centered medical homes, hospitals, national organizations, governments at the local, State, and Federal level, communities, providers, patients, as well as other stakeholders all have an important role to play in identifying social, economic, and environmental determinants, and ultimately improving health outcomes.”

RealTime Medicare Data CY 2020 Z Code Analytics

Analysis of CY 2020 Medicare Fee-for-Service paid claims data provided by our sister company, RealTime Medicare Data (RTMD), reinforced the current underuse of SDOH Z codes. For instance,

• Less than 1% of claims include a SDOH Z code for the Inpatient Hospitals, Outpatient Hospital and Part B places of service,
• Ninety-four percent of the claims were Hospital Outpatient claims, and
• Z59.0 (Homelessness) was the top Z code used in all three places of service.

MMP has compiled a high-level summary of the data analysis that can be downloaded here (link).

Using Z codes to Advance Health Equity

The American Hospital Association has been advocating for utilization of SDOH Z codes and publishing education for Providers since 2015 and have recently updated their ICD-10-CM Coding for Social Determinants of Health Fact Sheet (link).

In the January 13, 2022 edition of MLN Connects (link), the CMS promotes awareness of January being National Poverty in America Awareness Month noting that “37.2 million Americans living in poverty have an increased risk of chronic conditions, lower life expectancy, and barriers to quality health care; and racial and ethnic minorities have poverty rates more than twice that of white Americans. The COVID-19 pandemic has significantly affected these populations and low-income families.”

CMS is also promoting the use of Z codes to help advance health equity for all Americans by identifying poverty, unemployment, homelessness, and other social determinants.

Moving Forward

Ensure that key stakeholders in your facility (i.e., Physicians, Nurses, Social Workers, Case Managers, CDI Specialists, Registered Dieticians) receive education about SDOH and coding ICD-10-CM Z codes. A good place to start is with the guidance found in the ICD-10-CM Official Guidelines for Coding and Report FY 2022 (link). Additional resources available for your education efforts includes:

• CMS’ Using Z Codes infographic: (link)
• Office of Disease Prevention and Health Promotion – SDOH webpage: (link)
• CDC’s SDOH webpage: (link)
• AHA’s SDOH webpage: (link)