The Centers for Medicare & Medicaid Services (CMS) recently released its first report on the use of diagnostic codes for social determinants of health (SDoH) in Medicare claims since the Z codes were implemented in 2016. The main finding: It’s difficult for the government to capture consistent data because providers aren’t assigning Z codes even when patients reveal their SDoH concerns.

It’s been four years since CMS introduced ICD-10-CM codes that capture non-medical factors that influence a patient’s health status. But a new report reveals that providers aren’t consistently using the Z codes that identify a patient’s struggle with food insecurity, housing circumstances, transportation, and education and literacy.

CMS has pushed for the use of Z codes in response to a growing awareness of the importance of SDoH in patient health outcomes. The agency wants providers to collect and document this data in clinical settings to improve patient care. So far, it’s been difficult to collect the data because of inconsistent use of the codes, according to the report.  

The report does have several limitations as it only evaluates Medicare fee-for-service (FFS) claims through 2017 without taking Medicare Advantage into consideration. But as the first analysis of the 97 Z codes for SDoH, it provides insight into the industry’s understanding of SDoH factors that influence a patient’s overall health.  

Key findings

According to the report:

  • There was a 4.7 percent increase in the use of Z codes between 2016 and 2017
  • Only 1.4 percent (467,136) of the 33.7 million Medicare FFS beneficiaries in 2017 had Z code claims
  • Twenty-five percent of these beneficiaries were dual eligible for Medicare and Medicaid
  • Thirty-five percent of them were under the age of 65

The top five Z codes documented in 2017 were:

  1. Homelessness (Z590)
  2. Problems related to living alone (Z602)
  3. Disappearance and death of family member (Z634)
  4. Other specified problems related to psychosocial circumstances (Z658)
  5. Problems in relationship with spouse or partner (Z630)

  • The only Z code with a higher utilization for males rather than females was homelessness
  • The proportion of black and American Indian/Alaska Native beneficiaries who experience homelessness was more than three times higher than non-Hispanic white beneficiaries
  • The top five chronic conditions of beneficiaries with Z code claims were:
  1. Hypertension (72 percent)
  2. Depression (53 percent)
  3. Hyperlipidemia (48 percent)
  4. Rheumatoid arthritis/osteoarthritis (45 percent)
  5. Chronic kidney disease (38 percent)

Obstacles and possible solutions

CMS acknowledged in the report that there are several barriers to widespread use of SDoH codes, including the absence of a standardized EHR-based screening tool, the lack of and multiplicity of codes, and inadequate knowledge among providers and medical coders.

In a post on JDSupra, lawyers from Faeger Baker Daniels said that even though the existing Z codes don’t align perfectly with SDoH, they encouraged providers to use them as these codes are the only standardized mechanism that the industry has to gain deeper insight into the non-medical factors that contribute to patients’ health.

RELATED: UnitedHealthcare, American Medical Association push for 23 new ICD-10 codes to address social determinants of health

Meanwhile, two big industry players are working to expand ICD-10 Z codes to capture other SDoH, such as access to nutritious food, adequate and safe housing, available transportation, financial ability to pay for medications, financial ability to pay for utilities, and caregiver needs. UnitedHealthcare and the American Medical Association said they also want the codes to trigger referrals to social and government services, connecting patients directly to local and national resources in their communities. The codes were proposed last year to CMS’ ICD-10 Steering and Maintenance Committee and, if adopted, could take effect by Oct. 1.

The increased use of Z codes throughout the health care industry is critical, according to CMS. To improve the reporting of Z codes, CMS suggests providers implement policy-based interventions, reduce reliance on clinicians to capture SDoH, improve provider and medical coder education, and fill gaps in codes.

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