ICD-10-CM Coding for Social Determinants of Health (Z55-Z65)

There have been many new and revised codes for social determinants of health since the initial article posted here in June 2021. These “Z” codes are listed below, along with the ICD-10-CM coding guidelines (FY 2022) specific to SDOH “Z” code reporting. 

What Are Social Determinants of Health?

Our health is determined by how we take care of ourselves and the healthcare we receive from our physicians. Non-medical factors also determine our health, such as food, housing, transportation, and employment. These social and environmental factors that affect our health outcomes are known as social determinants of health (SDOH).

The Centers for Disease Control and Prevention (CDC) defines SDOH as “conditions in the places where people live, learn, work, and play that affect a wide range of health and quality of life risks and outcomes.”  

According to the World Health Organization (WHO):

• Social determinants can be more important than healthcare or lifestyle choices in influencing health.
• Studies suggest that SDOH accounts for between 30 and 55 percent of health outcomes.

Five Main Groups of SDOH

Social determinants of health (SDOH) are organized into five main groups:

• Economic Stability
• Education Access and Quality
• Healthcare Access and Quality
• Neighborhood and Built Environment
• Social and Community Context

The U.S. Department of Health and Human Services provides some examples of SDOH:

• Safe housing, transportation, and neighborhoods
• Racism, discrimination, and violence
• Education, job opportunities, and income
• Access to nutritious foods and physical activity opportunities
• Polluted air and water
• Language and literacy skills

Socially disadvantaged populations also experience preventable differences in death and loss of health due to disease, injury, violence, and opportunities to achieve the best possible health outcomes.

For example, a person without access to grocery stores with healthy foods is likelier to have poor nutrition. This puts the person at an increased risk of developing a condition such as heart disease, diabetes, and/or obesity, and even possibly a lower life expectancy as compared to a person with access to healthy foods.  That is why public health organizations need to work with sectors in the community, like education, transportation, and housing, to improve the conditions of people in their environments.   

How Does SDOH Affect Medical Coding?

Physicians are becoming much more aware of the significance of social and environmental factors and their impact on a patient’s health and health outcomes. Therefore, they are focusing more attention on SDOH to improve healthcare quality and reduce costs.

According to the Centers for Medicare & Medicaid Services (CMS), any person’s care team member may collect SDOH data and document it in the patient’s record. This non-medical information can be collected through health risk assessments, screening tools, person-to-provider interaction, and individual self-reporting. A medical coder should then assign the appropriate SDOH Z codes to tell the story of the patient’s experiences, circumstances, or problems that affect their health.

Coding for Social Determinants of Health

Many of the codes for these social factors are located in code block Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, within Chapter 21. Factors influencing health status and contact with health services.  

The ten code categories and their descriptions in this code block are:

• Z55, Problems related to education and literacy
• Z56, Problems related to employment and unemployment
• Z57, Occupational exposure to risk factors
• Z58, Problems related to physical environment
• 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

These categories are further broken down into subcategory codes to describe the specific non-medical problem. For example, category Z55, Problems related to education and literacy, is broken down into:

• Z55.0, Illiteracy and low-level literacy
• Z55.1, Schooling unavailable and unattainable
• Z55.2, Failed school examinations
• Z55.3, Underachievement in school
• Z55.4, Educational maladjustment and discord with teachers and classmates 
• Z55.5, Less than a high school diploma
• Z55.8, Other problems related to education and literacy
• Z55.9, Problems related to education and literacy, unspecified

Categories Z56-Z65 also have their own set of subcategory codes, which are not listed here.

Code Changes for FY 2022

New and revised codes that took effect October 1, 2021, include:

• Z55.5, Less than a high school diploma
• Z58.6, Inadequate drinking water supply
• Z59.0-, Homelessness, was expanded to include:
  Z59.01, Sheltered homelessness
  Z59.02, Unsheltered homelessness
• Z59.4 was revised from “Lack of adequate food and safe drinking water” to “Lack of adequate food” and expanded to include:
  Z59.41, Food insecurity
  Z59.48, Other specified lack of adequate food
• Z59.81, Housing instability, housed, was expanded to include:
  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
• Z59.89, Other problems related to housing and economic circumstances

ICD-10-CM Coding Guidelines

Coding for SDOH starts with knowing the ICD-10-CM coding guidelines. Z codes are diagnosis codes used in various healthcare settings. They are to be listed with the appropriate procedure codes when a procedure is performed. Z codes related to SDOH reported with codes from Z55-Z65 have their own specific guidelines. 

According to the ICD-10-CM Official Guidelines for Coding and Reporting (FY 2022):

“Codes describing social determinants of health (SDOH) should be assigned when this information is documented. For social determinants of health, such as information found in categories Z55-Z65, Persons with potential health hazards related to socioeconomic and psychosocial circumstances, code assignment may be based on medical record documentation from clinicians involved in the care of the patient who is not the patient’s provider since this information represents social information, rather than medical diagnoses. For example, coding professionals may utilize documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record.”

“Patient self-reported documentation may be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the medical record by either a clinician or provider.”

Check Your Knowledge

Based on what you have learned in this article, see if you can correctly answer the True/False questions. Then look at the answers below to see how you did.

1.  Many of the social determinants of health Z codes are located in code block Z55-Z65 of Chapter 21 and include ten code categories.
2. A clinician may not document a patient’s social information in the medical record.
3. Suppose a patient reports a potential health hazard. In that case, a medical coder may assign the appropriate Z code as long as a provider adds the information to the medical record.
4. Codes from categories Z55-Z65 are sequenced according to the circumstances of admissions.
5. A person has been having problems with his wife and lives in his vehicle. He is referred for community services. The coder would assign Z63.0 and Z59.02.

Answers

1. True. These SDOH Z codes from code block Z55-Z65 contain nine categories and can be found in Chapter 21. Factors influencing health status and contact with health services.
2. False. Clinicians involved in patient care may document this in the medical record because this is social information and not a medical diagnosis.
3. False. Suppose a patient reports a potential health hazard. In that case, a medical coder may assign the appropriate Z code if the information is signed off on and added to the medical record by a clinician or provider.
4. False. Codes from categories Z55-Z65 should only be reported as a secondary diagnosis.
5. True. Z63.0, Problems in relationship with spouse or partner, and Z59.02, Unsheltered homelessness, would be assigned. Although the documentation does not state “homelessness,” the documentation of “lives in his vehicle” justifies the assignment of Z59.02.

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