Updated on: February 18, 2020

Ignorance of the Social Determinants of Health is not Bliss

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Original story posted on: February 17, 2020

Understanding the ICD-10-CM Z codes is essential.

On Feb. 6, RACmonitor posted an article by Ellen Fink-Samnick, a frequent contributor to ICD10monitor and Talk Ten Tuesdays. It was titled “Underutilization of ICD-10-CM Z Codes for Medicare Beneficiaries.”

She reminded us that it’s been two years since we were given dispensation to use documentation from other professionals, as opposed to demanding that physicians document the circumstances of social determinants of health (SDoH). She noted that the January 2020 Centers for Medicare & Medicaid Services (CMS) Office of Minority Health Issue Brief reported that only 1.4 percent of traditional Medicare claims from 2016-2017 had Z codes, and the most common were:

  • Z59.0 Homelessness
  • Z60.2 Problems related to living alone
  • Z63.4 Disappearance and death of a family member
  • Z65.9 Other specified problems related to psychosocial circumstances
  • Z63.0 Problems in relationship with spouse or partner

When I was making 70 modules to teach providers about the sub-specialty levels of ICD-10, every day I was delighted to find a new and interesting code. There are more than 69,000 ICD-10-CM codes. I bet that most of the problem is that professionals like social workers and even coders don’t know the extent and breadth of the Z codes, as opposed to them recognizing that a social situation warrants a code, but choosing not to assign it.

Let’s explore the SDoH section, Z55 to Z65. For almost all the subcategories, there is an “other problems of” and “problems of, unspecified” code. Some of these codes may never be utilized in a hospital setting, but they might be more applicable in the office setting.

  • Z55, Problems related to education and literacy

There are codes for illiteracy and low-level literacy, schooling unavailable, underachievement in school, and educational maladjustment and discord with teachers and classmates. This might explain why a patient is unable to follow written discharge instructions or medication regimens.

  • Z56, Problems related to employment and unemployment

Being unemployed, having stress from a job (or from changing the job or from the threat of losing a job), discord with boss and workers, sexual harassment, and military deployment status comprise this subcategory. These SDoH conditions might factor into depression or many stress-related medical conditions.

  • Z57, Occupational exposure to risk factors

Occupational exposure to noise, radiation, dust, environmental tobacco smoke, toxic agents in agriculture or other industries, extreme temperature, and vibration are the more specific exposures with specific codes. ENTs, pulmonologists, and dermatologists might use these codes with regularity.

  • Z59, Problems related to housing and economic circumstances

This is where homelessness is found, a contender for a risk- and revenue-adjusting co-morbid condition. There is also inadequate housing; discord with neighbors, lodgers, and landlord; problems related to living in a residential institution; lack of adequate food and safe drinking water; extreme poverty and low income; insufficient social insurance; and welfare support. It seems like these codes would be common in any healthcare setting.

  • Z60, Problems related to social environment

This category includes problems of adjustment to life-cycle transitions related to living alone; social exclusion and rejection; target of perceived adverse discrimination and persecution; imagine if these codes were used as indicated. Maybe we could prevent mass shootings by getting patients the help they need.

  • Z62, Problems related to upbringing

Inadequate parental supervision or overprotection, or excessive parental pressure; being in welfare custody or institutionalized; personal history of abuse and neglect, of forced labor or sexual exploitation; conflict between parent and biological or adopted or foster child; or estrangement or sibling rivalry are examples of upbringing issues.

  • Z63, Other problems related to primary support group, including family circumstances

This was interesting to me. I think there is a code missing. There is a code for problems in relationship with spouse or partner and with in-laws, but there is no code for problems in relationship with parent. This category evokes an adult patient in my mind, and the Z62 codes don’t seem to equate with “problems in relationship with parents” to me.

The category also includes absence of family member due to military deployment, death, or disappearance; disruption of family by separation and divorce; stress due to return of family member from military deployment; alcoholism and drug addiction in family; all of these pose a powerful impact to a patient’s health and mental well-being.

I was also puzzled by the absence of my own personal circumstance: Z63.6 is for a dependent relative needing care at home. I think there should be a code for stress incurred by attending to a relative in an institutional setting, like the hospital, nursing home, group home, or prison.

  • Z64, Problems related to certain psychosocial circumstances

This subcategory contains problems related to unwanted pregnancy and to multiparity, which are not physical medical issues, I presume. Also included in this is discord with counselors, which seem to be social workers or probation officers.

  • Z65, Problems related to other psychosocial circumstances

This subcategory includes legal conviction, without or with imprisonment; problems related to release from prison; being a victim of crime or terrorism; and exposure to disaster, war, and other hostilities. It seems to me that this subcategory alone should be found on more than 1.4 percent of claims.

You could imagine that any given individual might have multiple SDoH codes that would tell the story of their particular circumstances. I think that ignorance of the wealth of codes available is a large part of the problem. I suggest that you spend a little time perusing the Z55-Z65 section, and familiarize yourself with your options.

I bet you will see that we all have challenging circumstances that should be taken into consideration when addressing our health needs.

Programming Note:

Listen to Dr. Remer report this story live today during Talk Ten Tuesday.

Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. She was a physician advisor of a large multi-hospital system for four years before transitioning to independent consulting in July 2016. Her passion is educating CDI specialists, coders, and healthcare providers with engaging, case-based presentations on documentation, CDI, and denials management topics. She has written numerous articles and serves as the co-host of Talk Ten Tuesdays, a weekly national podcast. Dr. Remer is a member of the ICD10monitor editorial board, the ACDIS Advisory Board, and the board of directors of the American College of Physician Advisors.

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