As previously reported for the proposed ruling, it was confirmed in the 2025 Inpatient Prospective Payment System (IPPS) Final Rule that the Centers for Medicare & Medicaid Services (CMS) is changing the severity level designation for the social determinants of health (SDoH) diagnosis codes denoting inadequate housing and housing instability, from non-complications or comorbidities (non-CCs) to CCs for the 2025 fiscal year (FY).
Consistent with the annual updates to account for changes in resource consumption, treatment patterns, and the clinical characteristics of patients, CMS will now reimburse for inadequate housing and housing instability as indicators of increased resource utilization in the acute inpatient hospital setting.
Inadequate housing is defined as an occupied housing unit that has moderate or severe physical problems, such as plumbing, heating, electricity, or upkeep issues. CMS describes concerns with patients living in inadequate housing by noting that they may be exposed to health and safety risks that impact healthcare services, such as vermin, mold, water leaks, and inadequate heating or cooling systems (see page 250).
The relevant codes include the following:
Please see my prior article on the rationale for this decision. I will also mention that the final rule does express notable interest in food insecurity, Z59.41, as a potential conversion to a CC; however, there was not enough data provided on this Z code to justify the conversion.
Instead of repeating that information, I would like to focus on some of the comments that were released in the final rule.
Generally, the public comments were widely supportive for the proposal to change the severity level designation for several ICD-10-CM diagnosis codes related to inadequate housing and housing instability from non-CCs to CCs for FY 2025. This change was seen as crucial for increasing healthcare access for underserved communities and recognizing the interconnectedness of health and social needs. CMS expects that the movement of these codes to CCs will improve data quality by encouraging providers to ask more detailed questions about patients’ housing status.
Despite the support, there were some continued issues raised regarding operational concerns, particularly the current limitation of only 25 diagnoses being captured on electronic claim forms and 19 on paper bills, which I believe was also mentioned in the FY 2024 Final Rule.
The known concern is that documenting SDoH Z codes could lead to overcrowding of other necessary diagnosis codes, potentially impacting payment and quality measures. Suggestions included expanding the number of diagnosis codes that can be reported or creating a separate reporting method for SDoH Z codes. CMS reminded us all again that these comments must be submitted to the National Uniform Billing Committee (NUBC), which maintains the Uniform Billing (UB) 04 data set and form.
Finally, some commenters expressed concern over CMS’s focus on SDoH Z codes, urging a comprehensive analysis of all diagnosis codes in the ICD-10-CM classification to ensure that MS-DRG payments align with the costs of patient care. They encouraged examining other SDoH Z codes related to food insecurity, extreme poverty, and other social factors to determine hospital resource utilization. Concerns were also raised about the challenges in documenting SDoH, including the lack of standard definitions, the need for training, and potential underreporting due to the sensitivity of the information.
CMS has confirmed that if SDoH Z codes are consistently reported on inpatient claims, the impact on resource use data may more adequately reflect what additional resources were expended to address these SDoH circumstances, in terms of requiring clinical evaluation, extended length of hospital stay, increased nursing care or monitoring (or both), and comprehensive discharge planning. CMS went on to say that they will re-examine these severity designations in future rulemaking. Moving forward, continuous dialogue and adjustments will be essential to address the operational challenges and further enhancements needed to impact the burden of resources related to social circumstances in the acute-care setting.
Today, I want to bring attention to an issue that is once again under scrutiny, how hospitals report patient harm events under the Centers for
As with many other physicians of a certain age, I have had the opportunity to practice patient care in both the worlds of paper and
Please log in to your account to comment on this article.
Master the complexities of heart failure coding with this expert-led webcast by Emily Montemayor, CCS, CMBCS, COC, CPC, CPMA. Discover strategies to ensure compliance with ICD-10-CM guidelines, documentation integrity, and capture comorbidities like CKD and hypertension. Learn how to resolve coding challenges, improve documentation practices, and submit clean claims to minimize denials and safeguard your organization’s financial health. With practical insights and real-world examples, this session equips you to prevent revenue leakage, enhance compliance, and secure optimal reimbursement—all while supporting better patient outcomes.
Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Copyright © 2025 ICD10monitor. Powered by MedLearn Media.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
