As reported back in April 2023 regarding the proposed ruling on social determinants of health (SDoH) Z-codes, I would like to update and celebrate the final ruling for Z59.00, unspecified homelessness, with subcategories of 59.01, and 59.02- sheltered and unsheltered homelessness. These will now be considered a complication or comorbidity (CC), based on the higher average cost to care for such individuals.
There were several comments and responses called out in this decision I thought were noteworthy to discuss (details are discussed from 293-309).
Commentators and the Centers for Medicare & Medicaid Services (CMS) concurred that greater alignment is needed between the SDoH quality submission requirements and SDoH Z-code capture, both recognizing that making homelessness a CC is a great first step, as this directly correlates with the social driver housing domain.
CMS also confirmed that they are continuing down the path of SDoH Z-code methodology for data capture to measure the impact on resource consumption, such as clinical evaluations, extended length of stay, increased nursing care, and comprehensive discharge planning, which is why continued collection is imperative for future analysis regarding reimbursement. There were requests for planning on future considerations for Z-codes to be considered as CCs/MCCs, but CMS shot this down, essentially saying they do not have enough data yet to make any statements. I would say that with the inclusion of questions regarding food insecurity as a social driver and the existing workflow for malnutrition in the coding and clinical documentation improvement specialist (CDIS) arena, this may be an easy alignment for coding, Z59.41, based off patient responses in the screening tool.
It was also noted in the final ruling that continued feedback regarding the addition of Z-code capture does not allow for enough space on the claim form, as we are limited to 25 diagnoses. CMS noted that this is not a part of their purview, and that these requests would need to be taken up with the National Uniform Billing Committee (NUBC) for adjustments to the UB04 data set and form.
Finally, commentators discussed concerns with their electronic health records (EHRs) and electronic coding tools, expressing a desire to stay up-to-date with Z code-recognition and capture. CMS stated that on April 18, the Office of the National Coordinator proposed updating certification standards that if finalized, would require certified EHR vendors to include four SDoH data elements in their products: SDoH assessment, goals, interventions, and problems/health concerns.
I am excited to see the continued momentum toward recognizing the SDoH of our patients and how this impacts their medical care and system resource utilization. If hospitals and health systems have not already begun this process, they should start working on determining how they are going to increase Z-code capture and really start pushing their electronic coding vendors to make sure they are updating their tools for coders and CDISs.
Programming note: Listen to live SDoH reports by Tiffany Ferguson, every Tuesday on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.
References:
https://public-inspection.federalregister.gov/2023-16252.pdf
The Centers for Medicare & Medicaid Services (CMS) released in its 2025 Outpatient Prospective Payment System (OPPS) Final Rule a new Conditions of Participation (CoPs)
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