Coding for social determinants of health (Z55-Z65) can be quite challenging. Learn about these potential health hazards, how to code for them in ICD-10-CM, and the coding guidelines specific to SDOH Z code reporting.
Our health is determined by the way we take care of ourselves and the healthcare we receive from our physicians. There are also non-medical factors that 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 account for between 30 and 55 percent of health outcomes.
Social Determinants of Health (SDOH)
Social determinants of health (SDOH) is organized into five main groups:
- Healthcare access and quality
- Education access and quality
- Social and community context
- Economic stability
- Neighborhood and built environment
The U.S. Department of Health and Human Services provides some examples of SDOH as:
- 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 who has no access to grocery stores with healthy foods is more likely 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 it is important for public health organizations 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 the quality of healthcare and to reduce costs.
According to the Centers for Medicare & Medicaid Services (CMS), any member of a person’s care team 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 may then assign the appropriate SDOH Z codes to tell the story of the patient’s experiences, circumstances, or problems that affect his/her health. This reporting identifies a diverse population with complex needs. It also helps to ensure that proper resources are set aside for these people who often have chronic conditions and worsening outcomes.
The increase in assigning codes for SDOH does have its challenges. Providers still need to be educated on screening and coding for SDOH. There are gaps in the ICD-10-CM classification system related to SDOH codes which make it difficult to capture and exchange SDOH data.
There are also a lack of of definitions for SDOH terms. However, according to the National Health Care for the Homeless Council, some providers, hospitals and/or managed care plans have developed their own coding systems to make it easier to capture and code for the SDOH. For example, Z59.0, Homelessness, may be assigned when the documentation indicates something other than “homelessness” or “homeless” such as as “living in vehicle,” “no fixed address,” “living in a tent,” or “living in a shelter.”
Coding for Social Determinants of Health
Social determinants of health Z codes are the codes used to provide useful information on circumstances that may affect a patient’s care and treatment. 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.
There are nine code categories and descriptions in this code block:
- 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
These categories are further broken down into subcategory codes to describe the specific non-medical problem.
For example, category Z55 is broken down into:
- Z55.0, Illiteracy and low-level literacy
- Z55.1, Schooling unavailable or unattainable
- Z55.2, Failed school examinations
- Z55.3, Underachievement in school
- Z55.4, Educational maladjustment and discord with teachers and classmates
- 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.
The five most commonly used Z codes among Medicare FFS beneficiaries in 2017, according to CMS, 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
- Z63.0, Problems in relationship with spouse or partner
ICD-10-CM Coding Guidelines
Coding for SDOH starts with knowing the ICD-10-CM coding guidelines. Z codes are diagnosis codes that are used in various healthcare settings, but they are not required nationally. They are to be listed with the appropriate procedure codes when a procedure code is performed.
Z codes related to SDOH that are reported with codes from Z55-Z65 have their own specific guidelines. According to the ICD-10-CM Official Guidelines for Coding and Reporting (FY 2021):
“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 are not the patient’s provider since this information represents social information, rather than medical diagnoses. Patient self-reported documentation may also 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 health record by either a clinician or provider. …The BMI, coma scale, NIHSS codes and categories Z55-Z65 should only be reported as secondary diagnoses.”
According to the American Hospital Association, a “clinician” may include, but is not limited to, social workers, community health workers, case managers, nurses, or other providers.
Check Your Knowledge
Based on what you have learned in this article, see if you can answer the True/False questions correctly. Then look at the answers below to see how you did.
- Many of the social determinants of health Z codes codes are located in code block Z55-Z65 of Chapter 21 and include 9 code categories.
- A clinician may not document a patient’s social information in the medical record.
- If a patient reports a potential health hazard, a medical coder may assign the appropriate Z code as long as the information is added to the medical record by a provider.
- Codes from categories Z55-Z65 are sequenced according to the circumstances of admissions.
- 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 Z59.0.
- True. These SDOH Z codes from code block Z55-Z65 contains 9 categories and can be found in Chapter 21. Factors influencing health status and contact with health services.
- False. Clinicians who are involved in the care of the patient may document in the medical record because this is social information and not a medical diagnosis.
- False. If a patient reports a potential health hazard, a medical coder may assign the appropriate Z code as long as the information is signed off on and added to the medical record by a clinician or provider.
- False. Codes from categories Z55-Z65 should only be reported as a secondary diagnosis.
- True. Z63.0, Problems in relationship with spouse or partner, and Z59.0, Homelessness, would be assigned. Although the documentation does not state “homelessness,” the documentation of “lives in his vehicle” justifies the assignment of Z59.0.
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