Leveraging Z Codes in Health Equity Strategies

When it comes to health equity, one of the most significant advances was the transition to the ICD-10 code set, which created an environment rich with data detailing social determinants of health (SDoH). It also expanded the role of coders and revenue cycle management professionals in health equity by expanding the volume of data they interact with daily that informs health equity strategies.

In fact, code sets and coding guidelines have continued to expand over the years specifically to capture SDoH information at a level not possible with other data sources. A prime example is the introduction of ICD-10-CM Z codes, which can be used to record highly detailed SDoH directly into the patient’s record, providing deeper insights into factors impacting health.

For example, low literacy is linked to poor health outcomes and less frequent use of prevention and wellness services, leading to more frequent and longer hospital stays. It is captured with Z55, problems related to education and literacy, including such risk factors as illiteracy, schooling unavailable, underachievement in school, educational maladjustment, and discord with teachers and classmates.

Z56 captures details around problems related to employment and unemployment, the latter of which is linked to declining self-reported health status and increased mortality rates for males and females ages 16-64. It is also linked to quadruple rates of drug and substance abuse and dependence and double the chances of being diagnosed with a mental disorder such as depression or general anxiety disorder.

Homelessness are food insecurity are among the top three most important factors for determining and addressing SDoH needs related to health outcomes and are captured via Z59 – problems related to housing and economic circumstances. This category also captures detail around risk factors including inadequate housing, discord with neighbors, lodgers, and landlords, problems related to living in residential institutions, lack of adequate food and safe drinking water, extreme poverty, low income, and insufficient social insurance and welfare support. The third factor is isolation, which is captured under Z60, as problems related to social environment. Problems and risk factors included in this category are adjustments to life-cycle transitions, living alone, acculturation difficulty, social exclusion and rejection, and target of adverse discrimination and persecution.

The use of Z codes to capture detail around SDoH has been embraced by healthcare organizations. In fact, in 2019, among the 33.1 million continuously enrolled Medicare fee-for-service beneficiaries, 1.59% had claims with Z codes. The top five most utilized 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).

In many cases, documentation from third-party services like social and community health workers, case managers, nurses, and self-reported information is vital to painting a comprehensive portrait of a population’s SDoH. The ability to include this documentation within the patient’s official medical record is having a significant impact on addressing SDoH and narrowing the health equity gap.  Specifically, capturing this level of detail around SDoH allows needs to be more accurately assessed so patients can be connected to community services to address them.

Ultimately, when SDoH data is standardized within the electronic record, it not only improves health, lowers costs, and advances health equity, but enables healthcare organizations to develop sustainable business models to fund access to community services.