Social Determinants of Health: Applying Knowledge to Improve Health and Advance Health Equity – Part 2

Codes Z55-Z65 are found in Chapter 21: Factors influencing health status and contact with health services psychosocial circumstances.

This range of codes is organized into one code block, Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances. The code categories within this code block are:

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

• Note that these are code categories; the valid codes are found within each code category. To familiarize yourself with the valid codes, which are too numerous to list here, we recommend a review of each of these categories and the valid codes within.

Now that you have learned more about the importance of collecting SDOH Z-codes, are there any in code block Z55-Z65 that you think would be important to code and report, but are not? If so, why not?

The American Hospital Association (AHA) and SDOH

The AHA describes the importance of SDOH data collection and analysis as follows:

“Robust data related to patients’ social needs is critical to hospitals’ efforts to improve the health of their patients and communities. And, employing a standardized approach to screening for, documenting and coding social needs will enable hospitals to:

• Track the social needs that impact their patients, allowing for personalized care that addresses patients medical and social needs;
• Aggregate data across patients to determine how to focus a social determinants strategy; and
• Identify population health trends and guide community partnerships. One tool available to hospitals to capture data on the social needs of their patient population is the ICD-10-CM codes included in categories Z55-Z65 (SDOH Z-codes), which identify non-medical factors that may influence a patient’s health status.”

The AHA continued “Despite the availability and utility of these ICD-10-CM codes, hospitals have not widely adopted the use of Z-codes. Adoption has been limited due to a lack of clarity on who can document a patient’s social needs, absence of operational processes for documenting and coding social needs, and unfamiliarity with Z-codes. In addition, coders may need encouragement and support from hospital leaders to collect these codes that were once perceived as a lower priority.”

If we coders didn’t already, we can now appreciate the importance of data and information related to SDOH. We know that some of the data comes from sources other than the patient health record, for example surveys or community forums and is not “codeable.” But what about the available data that are “codable?” Is this data coded and reported? And what about data that simply are not being documented?

Let’s take a look at the AHA’s list of reasons why data available to the coder, data in the patient health record, are not necessarily being coded and reported.

1. Lack of clarity on who can document a patient’s social needs

This was addressed or can be addressed, as follows:

• The ICD-10-CM Official Guidelines for Coding and Reporting, 1.B.14.Documentation by Clinicians Other than the Patient’s Provider was revised in FY 2019 for specific guidance for coding professionals.
• Medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider can be used for code assignment for the social determinants of health (codes in categories Z55-Z65) reported data.
• A Q&A in the AHA Coding Clinic, Volume 6, Number 4, 4^thQuarter 2019, pgs. 67-68, states that the guidelines do not have a unique definition of “clinicians” but documentation that meets the requirements based on regulatory or accreditation requirements or internal hospital policies, could be used for code assignment for SDOH Z-codes.
• AHA Coding Clinic, Volume 6, Number 4, 4^thQuarter 2019, pgs. 66-67 also provides guidance that “If the patient self-reported information is signed-off and incorporated into the health record by either a clinician or provider, it would be appropriate to assign codes from categories Z55-Z65, describing social determinants of health.”

2. Absence of operational processes for documenting social needs

• Educate key stakeholders, including physicians, non-physician health care providers, and coding professionals of the important need to screen and document social needs. The AHA PowerPoint referenced earlier is an excellent start.
• Note that providers are also asking physicians and other clinical healthcare workers to document SDOH. See the United Healthcare website as an example:

3. Absence of operational processes for coding social needs

• Educate coding professionals of the important need to code and report data on patients’ social needs. The AHA PowerPoint referenced earlier is an excellent start.

4. Unfamiliarity with Z codes

Since ICD-10-CM was adopted for use October 1, 2015, one would think that by now, coders are familiar with Z-codes. But, as the coder mantra goes, “never assume.” A review of Chapter 21 may actually reveal an unfamiliarity of the many code options available for factors not frequently seen or perhaps considered insignificant or irrelevant, such as Z56.3 Stressful work schedule. Don’t most people have a stressful work schedule? How about Z62.891 Sibling rivalry? Wouldn’t that apply to everybody with a brother or sister? Maybe so, but in the context of the patient encounter, these factors may be significant – and there are Z-codes available to assign if they are!

Briefly, there are 15 chapter blocks in Chapter 21. Factors Influencing Heath Status and Contact with Health Services (Z00-Z99). Most coders probably have been coding and reporting many codes from this chapter, such as those in category Z16 Resistance to antimicrobial drugs, Z66 Do not resuscitate status, and codes in category Z68 Body mass index (BMI), but not necessarily the SDOH range of Z-codes.

As noted, Z-codes for SDOH are all in the same chapter block, Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances. As the chapter block title suggests, these are codes for social, economic and psychosocial circumstances that may present as a hazard to a patient.

Please take a minute or so and think about where you might find the documentation in the patient record to support coding and reporting any of the codes in the code categories ranging from Z55-Z65, as listed below.

• Coding Notes:
  • These Z-codes should never be reported as the principal diagnosis code or first-listed code
  • Documentation must support the assignment and reporting of these codes
  • Follow the Official Guideline for Coding and Reporting Section III. Reporting Additional Diagnoses

5. Lack of encouragement and support from hospital leaders to collect codes once perceived as a lower priority

In some facilities, many Z codes are of lower priority and are not coded because (1) they do not affect MS-DRG assignment, and (2) time spent searching for documentation to support assignment of Z codes, including the SDOH Z codes Z55-Z65, can have a negative effect on overall productivity. However, there is increasing awareness of the conditions that the current Z codes represent and how the data and information they provide may assist in improving patient and population health, improving patient outcomes, and reducing the per capita cost of health care – these are high priorities.

For example, codes in category Z59 Problems related to housing and economic circumstances are codes that can have a major impact on a hospital’s risk model, which includes the expected mortality, length of stay, and cost per patient. When a patient in an acute hospital has any of the conditions below, it increases the length of stay and adds additional cost to the provider.  In addition, studies have shown that Z59.0, Homelessness, is a determining factor in readmission rates. Are the “problems” in this example documented in the patient record? If so, are the codes being reported by your facility?

Z59 – Problems related to housing and economic circumstances

Z59.0 – Homelessness
Z59.1 – Inadequate housing
Z59.4 – Lack of adequate food and safe drinking water
Z59.5 – Extreme poverty
Z59.6 – Low income
Z59.7 – Insufficient social insurance and welfare support

Proposed New Z-codes

New Z-codes were proposed in April 2019 by UnitedHealthcare and the American Medical Association to add over 20 new Z codes, under the existing social determinants of health (SDOH) categories Z55-Z65.1 An additional proposal was made by Blue Cross Blue Shield of Vermont and Yale School of Nursing to specifically add subcategory Z-codes related to food insecurity.

These proposed Z-codes are expansions of existing code categories; for example:

Z59.4 Lack of adequate food and safe drinking water (current, existing code)

Z59.41 Lack of adequate food (proposed code)

Z59.42 Food insecurity (proposed code)

Z59.43 Lack of safe drinking water (proposed code)

Here is a link to all of the proposed Z codes. Also, see here.

Summary

Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work and age.

A “determinant” is defined as a factor that decisively affects the nature or outcome of something.

SDOH groups these factors into categories. There are five categories, or key areas, of SDOH defined by the CDC in their “Healthy People 2020” initiative. They are

• Economic Stability
• Education
• Social and Community Context
• Health and Health Care
• Neighborhood and Built Environment

The goal of addressing SDOH is to “create social and physical environments that promote health for all.”

The American Hospital Association (AHA) is one organization that stresses and describes the importance or SDOH data collection and analysis.

The AHA has identified reasons why SDOH Z-codes Z55-Z65 have not been widely adopted, and offers solutions.

New SDOH Z-codes have been proposed but have not yet been implemented for use.