Z-Codes, designed to document Social Determinants of Health (SDOH), remain significantly underutilized, as highlighted by independent studies. Despite their integration into the healthcare coding process, these codes are scarcely used to track diverse SDOH. Research from NYU School of Global Public Health reveals limited Z-code application beyond housing insecurity in surveyed hospitals, while findings from Colorado School of Public Health and Johns Hopkins show stark differences in Z-code usage between Medicaid and commercially insured patients. The studies emphasize the need for comprehensive training programs, robust systems, and greater awareness to address this notable gap in documenting crucial social factors impacting patient health.
The integration of Z-Codes within the ICD-10 framework aimed to enable healthcare institutions to effectively document and track the diverse range of Social Determinants of Health (SDOH) impacting patient well-being. However, recent research from multiple institutions, including NYU School of Global Public Health and Colorado School of Public Health along with Johns Hopkins, indicates a substantial underutilization of these codes. Despite their potential to capture various SDOH domains, studies reveal a predominant use limited to housing insecurity and stark disparities in Z-code usage among Medicaid and commercially insured patients. This analysis raises concerns about the healthcare system’s readiness in comprehensively addressing the multifaceted social factors influencing patient health.
The initial study conducted by researchers from NYU School of Global Public Health emphasized the limited use of Z-codes across diverse social determinants of health. While over half of the hospitals examined utilized the Z-code for housing insecurity, the overall application of Z-codes was meager in other areas, underscoring a lack of comprehensive documentation.
The second study, carried out by experts from the Colorado School of Public Health and Johns Hopkins, disclosed a 50 percent higher prevalence of Z-code usage in the Medicaid population compared to commercially insured patients. Furthermore, these codes were predominantly employed within mental health or psychiatric settings.
Z-codes were introduced as part of the healthcare coding process to address the industry’s increasing focus on social determinants of health (SDOH). Falling within the ICD-10 framework, these codes offer healthcare providers a means to record SDOH diagnoses for patients, aligning with evolving payment models that integrate quality measures related to identifying and mitigating SDOH.
Several common SDOH are covered by Z-codes, encompassing education and literacy, employment, occupational exposure, housing and economic circumstances, social environment, upbringing, primary support group, psychosocial circumstances, physical environment, and other psychosocial circumstances.
Despite their potential utility, empirical evidence indicates a conspicuous underuse of Z-codes. The NYU researchers found that approximately 56 percent of nearly 6,000 US hospitals surveyed applied at least one Z-code to a patient annually, yet the diversity in Z-code usage was lacking. Z59, pertaining to housing and economic circumstances, emerged as the most frequently used Z-code, employed by 56 percent of the observed hospitals, while less than 10 percent utilized other Z-code types.
The study noted that general medicine hospitals, teaching hospitals, those affiliated with larger health systems, and medium to large-sized establishments exhibited higher likelihoods of Z-code usage. This discrepancy raises concerns about healthcare settings’ readiness and emphasis on a holistic understanding of SDOH.
The researchers highlighted the necessity for comprehensive training programs emphasizing the importance of all SDOH domains, coupled with robust systems and partnerships to address diverse non-medical needs beyond housing that patients may present.
The second study echoed similar findings regarding the low utilization of Z-codes and disparities in their application among different patient demographics. An analysis of Z-codes based on type, setting, and patient characteristics revealed a 50 percent higher utilization among Medicaid patients than those with commercial insurance.
The divergence in Z-code documentation between Medicaid and commercially insured patients was notable. Medicaid patients were more likely to receive Z-codes related to economic hardships, whereas commercially insured patients tended to have codes linked to social relationships.
Furthermore, discrepancies were observed in the settings where patients received Z-codes in their medical records. Mental health and psychiatric settings were the most common locations for Z-code documentation, yet Medicaid patients were more likely to receive Z-codes in inpatient settings, while commercially insured patients were more inclined to have these codes in outpatient settings.
Jason Gibbons, Ph.D., the lead author of the second study and an assistant professor and health economist at the Colorado School of Public Health at CU Anschutz, emphasized the critical need for healthcare facilities to identify and document social factors impacting patient health comprehensively. However, the glaring underutilization of the system designed to track these factors underscores a pressing issue that demands attention.
Gibbons advocated for the integration of Z-codes into specific quality payment models and 1115 waiver programs to encourage wider adoption. He stressed the importance of greater provider education as a pivotal step towards addressing this issue.
The studies examining the usage of Z-Codes in documenting Social Determinants of Health (SDOH) highlight a significant gap in their application across diverse healthcare settings. While Z-Codes were envisioned to comprehensively capture various SDOH domains, their underutilization beyond housing insecurity signifies a substantial limitation in addressing broader social factors impacting patient health. Addressing this gap demands comprehensive training initiatives, robust systems, and a heightened emphasis on broader SDOH domains. Integrating Z-Codes into quality payment models and enhancing provider education can play pivotal roles in bridging this gap, ensuring a more holistic approach towards understanding and addressing social factors influencing patient well-being.
