In health care circles these days, you hear about the social determinants of health (SDOH) almost as often as you hear: “You’re on mute!” SDOH are the conditions in the places where people are born, live, learn, work, play, worship, and age that affect health outcomes. These non-medical factors like income, socioeconomic status and access to health care, safe housing, and reliable transportation drive more than 80 percent of health outcomes. Conversely, medical care accounts for no more than 20 percent of patient outcomes — very sobering.
International Classification of Diseases (ICD) codes, published by the World Health Organization, are used to classify diseases and related health problems. ICD, Tenth Revision, Clinical Modification (ICD-10-CM) codes have been used in the U.S. since 2015. ICD-10-CM contains a subset of codes, Z55–Z66, the SDOH-related Z codes, that are used to document SDOH-related data.
The coding guidelines initially required documentation by a physician for these Z codes to be reported. So unmet social needs documented by non-physicians, such as social workers and nurses, could not be reported. To promote the utilization of Z codes, the American Hospital Association provided clarification in 2018 that allowed unmet social needs documented by non-physicians to be used by coders to assign SDOH-related Z codes. Although this change was associated with an increase in utilization, SDOH-related Z codes remain underutilized.
An analysis of utilization of Z codes for SDOH among Medicare fee-for-service (FFS) beneficiaries found that among the 33.1 million continuously enrolled Medicare beneficiaries in 2019, 1.59 percent had claims with Z codes — an increase from 1.31 percent in 2016. The top five categories of clinicians providing codes were physicians in family medicine, internal medicine and psychiatry, nurse practitioners and licensed social workers. The five most utilized codes were Z59.0 (homelessness), Z63.4 (disappearance and death of family member), Z60.2 (problems related to living alone), Z59.3 (problems related to living in a residential institution), and Z63.0 (problems in a relationship with spouse or partner).
Barriers to the documentation of Z codes include lack of clarity on who can document patients’ social needs, lack of systems and processes for documenting and coding social needs, unfamiliarity with SDOH-related Z codes and a low priority placed on the collection of this data previously.
Additional barriers have included lack of financial incentive as Z codes have not generally been used for payment purposes, the limited number of Z codes, limited or lack of training regarding Z codes — and clinicians feeling limited in what they can do and/or requiring guidance in assisting patients once non-medical needs have been identified.
As of January 1, 2021, evaluation and management (E/M) coding for office and outpatient services changed significantly such that coding is based either on the level of medical decision making (MDM) or the total time spent performing the service on the day of the encounter. The three elements of MDM include the number and complexity of problems addressed during the encounter, the amount and/or complexity of data reviewed and analyzed, and the risk of complications and/or morbidity or mortality of patient management decisions made at the visit. The four levels of MDM are straightforward, low, moderate, and high.
To qualify for a level of MDM, two of the three elements for that level must be met or exceeded. Diagnosis or treatment significantly limited by SDOH is an example of moderate risk. Documenting an SDOH-related Z code when relevant to the patient encounter gets risk to moderate. If either of the other two MDM elements is also moderate, the encounter can be coded at the moderate level (Level 4).
The ability to incorporate Z codes into E/M coding in 2021 may facilitate increased utilization and could significantly impact disease management, population and public health, and reimbursement. My excitement is dampened by the realization that the increase in the utilization of these Z codes may not be as substantial as one would hope. There are key considerations for effectively incorporating this into my practice:
- All members of my patient’s care team must be aware that they can collect SDOH-related data.
- Training in the collection and reporting of SDOH-related data is required for all team members.
- The process cannot be cumbersome and must not significantly disrupt workflow. A process that is tedious and involves multiple additional mouse clicks or navigation across multiple screens in the electronic medical record (EMR) would not be easily integrated or sustainable in a busy practice.
- Systems must be in place to connect my patients with the appropriate services to address their unmet social needs. Otherwise, why put a patient in the position of disclosing vulnerable information simply to collect data? Without a clear, user-friendly process for referral to social services, it would feel like I’m opening a can of worms and taking responsibility for an issue that I am not equipped to address.
So, how do I envision this working?
Let’s say I’m seeing a new patient with an overactive bladder. She indicates that she is experiencing homelessness on a social needs screening tool, which is available in hard copy and online and can be self-administered or administered by clinic staff.
We discuss the impact of homelessness on her ability to implement behavioral/dietary modification and complete a voiding diary. I document ICD-10 codes N32.81 (overactive bladder) and Z59.0 (homelessness). Entering Z59.0 into the EMR triggers an automatic pop-up for a referral to the social worker and automatically populates the patient’s visit instructions with links to resources such as FindHelp.org, where she finds resources for free or reduced-cost services and programs like financial and housing assistance and food pantries. In this ideal scenario, a social worker will be available and have appropriate funding, and documentation of this patient’s unmet social needs does not require 20 mouse clicks and a million pop-ups.
Now we come back to reality where documentation of unmet social needs is a daunting task if clinicians must bear the brunt of the work for connecting each patient with the appropriate social services. Provision of the necessary social services will require the investment of time, funding, and human resources. A collaborative systems-based approach involving hospital systems, insurers, community-based organizations, and local and federal government will be needed to ensure that clinicians in large hospital systems and solo practices alike are provided with the tools needed to help address their patients’ unmet social needs.
The Congressional SDOH Caucus launched in July 2021 to “explore opportunities to improve the impact of services delivered to address social determinants with the support of federal funding.” This bipartisan caucus will highlight the opportunities to coordinate federal investments in SDOH such as health, food, housing, and transportation. There are currently 163 SDOH and 52 health equity/disparities bills in Congress, an increase from 31 SDOH and 23 health disparities bills in the previous Congress. Clearly, SDOH is getting a lot of attention. I am cautiously optimistic that will translate into meaningful change for affected patients.
Gjanje L. Smith is a urologist.
Image credit: Shutterstock.com