CMS Analysis Finds SDoH Z Code Use on the Rise, But Still Underutilized

A truth of hospital charges is that a condition does not exist if there is no ICD-10 code to document a condition. A recently (January 2020) released CMS study, which administers Medicare and Medicaid, finds that the use of Z codes to document social determinants of health (SDoH) increased 5% for Medicare fee-for-service patients from 2016 to 2017. It is a noteworthy trend as SDoH are non-medical factors that negatively impact 80-90 percent of health status.

CMS said that the report was the first to analyze claim data for the utilization of Z codes. The Z codes identify non-medical SDoH factors within the Medicare population that influence a patient’s health due to socioeconomic factors. Unaddressed SDoH increases the cost of health care due to frequency and intensity, such as increasing ER use as opposed to managing chronic conditions through community outreach workers or primary care providers. CMS DR-10 SDoH Z codes are:

Z55 – Problems related to education and literacy

              Z56 – Problems related to employment or underemployment

Z57 – Occupational exposure to risk factors

Z59 – Problems related to housing and economic factors

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

Currently, DRG-10 users have nine categories of Z codes related to SDoH and several sub-codes, for a total of 97 designators. The CMS study found that about 1.4% of Medicare claims, numbering just shy of half a million, were tagged with Z codes. The five most common Z code claims were for:

Z59.0 – Homelessness

              Z60.2 – Problems related to living alone

Z63.4 – Disappearance and death of a family member

Z65.8 – Other specified problems related to psychosocial circumstances

Z63.0 – Problems in relationship with spouse or partner

The Z codes were established to create a better database for addressing SDoH patient stressors.

“More widely adopted and consistent documentation is needed to more comprehensively identify social needs, and monitor progress in addressing them. Collaboration between beneficiaries, community groups, and health care providers will be necessary to address the social determinants of health adequately and ultimately to improve health outcomes.,” the report noted.

Data collection and analysis were front and center in the CMS report. The reports cited a 2014 National Academies of Medicine report that advocated the use of SDoH collection methods in electronic health records to “empower providers” to both improve SDoH-related health disparities and to advance SDoH research. Further, according to CMS, a primary challenge is that currently, SDoH information is not consistently standardized and captured.

In addition, the CMS study also reported on the top ten chronic conditions among Medicare beneficiaries with Z code designations in 2017. These included: 

– Hypertension (72%)

– Depression (53%)

– Hyperlipidemia (48%)

– Rheumatoid Arthritis/Osteoarthritis (45%)

– Chronic Kidney Disease (38%)

– Anemia (38%)

– Ischemic Heart Disease (36%)

– Diabetes (34%)

– Chronic Obstructive Pulmonary Disease (25%)

– Congestive Heart Failure (25%)

The report noted that about 25% of SDoH Z code beneficiaries were dual-eligible for both Medicare and Medicaid. The report also cited “a number of challenges and potential solutions” to improve the use of Z codes to overcome low utilization. This would include participation by social workers, as well as attending clinicians.

“The findings of this study may represent an under count of assessments of the patient social needs. A recent study found that 24% of hospitals and 16% of physician practices screened for food insecurity, housing instability, utilities, transportation, and interpersonal violence,” according to the study authors.

Blog Sources:

More Topics

ClientConnect 2023, our inaugural peer-to-peer conference for human services organizations, was a resounding success! But if you missed out, don’t let that …

Climate change is affecting human life economically and sociopolitically, and vulnerable populations often have little recourse to protect themselves from the elements. …

Victim service providers help individuals and families fleeing domestic violence. However, providers face additional complexity when it comes to protecting their clients’ …

Contact Us