Social determinants of health, oftentimes abbreviated as (SDOH) are the economic and social conditions in which people are born, live, grow, work and age in. They may impact a wide range of health and quality of life risks and outcomes for patients. What are they? They can be things such as a history of physical abuse, homelessness, economic circumstances affecting health care, social exclusion and rejection, and problems related to education and literacy. Although these types of determinants may be documented within the medical record, they have not always been coded by coders. Now more than ever, it is important that they be reported.
They are best captured by the ICD-10-CM codes within Chapter 21: Factors influencing health status and contact with health services (Z00-Z99). Below are some of the broad categories of SDOH codes:
Persons with potential health hazards related to socioeconomic and psychosocial circumstances (Z55-Z65)
- Z55 Problems related to education and literacy
- Z56 Problems related to employment and unemployment
- Z57 Occupational exposure to risk factors
- Z59 Problems related to housing and economic circumstances
- Z60 Problems related to social environment
- Z62 Problems related to upbringing
- Z63 Other problems related to primary support group, including family circumstances
- Z64 Problems related to certain psychosocial circumstances
- Z65 Problems related to other psychosocial circumstances
How Are Social Determinants of Health Codes Used?
The data collected from claims with reported SDOH codes is being used by CMS to analyze data and health trends. This document by CMS highlights how CMS is using the data: https://www.cms.gov/files/document/z-codes-data-highlight.pdf PLEASE READ THIS DOCUMENT IN ITS ENTIRETY.
For example, of the 33.1 million total Medicare fee for service beneficiaries in 2019, approximately 1.59% had claims with Z codes as compared to 1.31% in 2016. The 5 most utilized Z codes from this article were:
- Z59.0 – Homelessness
- Z60.2 – Problems related to living alone
- Z63.4 – Disappearance and death of family member
- Z65.8 – Other specified problems related to psychosocial circumstances, and
- Z63.0 – Problems in relationship with spouse or partner
KEEP IN MIND THIS IS NOT THE ENTIRE LIST!
The worse conditions have been shown to negatively affect outcomes such as hospital readmission rates, length of stay, and use of post-acute care services. A 2014 National Academies of Medicine (NAM) report suggested that the collection of SDOH data in an electronic health record Is necessary to empower providers to address health disparities and to support further research on the effects of SDOH.
For example, of the 467,136 Medicare FFS beneficiaries in 2017 with Z code claims, 334,373 individuals which represents 72% had hypertension, and 248,726 individuals which is 53% had depression. You can see where the use of the SDOH data can be helpful in various ways.
The data source for the study in Medicare claims came from the CMS Chronic Condition Data Warehouse (CCW) (www.ccwdata.org)
Also, as mentioned, hospital quality measures can be impacted by SDOH coding and thus hospital reimbursement. This is true whether inpatient, outpatient or ER visit so it is important to report these codes on all patient claims!
What is a Coder to Do?
Coders are not new to “Z” codes and have frequently assigned these for things such as personal and family histories, statuses and for long term use of drugs, among other things. Coders should become familiar with Z codes that include SDOH if they have not already. Usually coders put little emphasis and time on finding SDOH in the EHR and coding them. However this is changing and coders should begin to identify the documented SDOH and code them in ICD-10-CM when documented and codes are available. They do not necessarily have to be documented by the actual physician or provider. According to AHA Coding Clinic, 1Q2018 page 18, categories Z55-Z65 are acceptable to report based on information documented by other clinicians involved in the care of the patient. That means that coders can code SDOH from nursing and other documentation.
The coder should check with their facility to see if there are specific areas in the EHR where this is documented if it is not evident. Coders are going to be seeing the documentation of SDOH increasing. I encourage all coders to read the article in the link below under “References” so they can see the breadth of the use of this data.
As we can see above, the use of coded data is becoming more and more robust and required in an ever changing healthcare world.
Homelessness Codes Now a CC
As of October 1, 2023, the homelessness codes below are now a CC in the MS-DRG system! It is important that this is documented well within the medical record and coded by coders:
- Z59.00 Homelessness unspecified
- Z59.01 Sheltered homelessness
- Z59.02 Unsheltered homelessness
See also Addendum 6J.1 of IPPS tables.
References
cdc.gov/socialdeterminants/index.htm
aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf
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The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.
