CMS Proposes Codes for Homelessness

CMS IPPS for 2020 takes a giant step forward.

For those who somehow missed it, there are 88 current ICD-10-CM Z codes and subcategories that encompass psychosocial and socioeconomic circumstances: Z55-65. One of these codes is Z59: Problems related to housing and economic circumstances. These Z codes have been part of the healthcare landscape for several years now, so if you’re thinking “these aren’t new,” you are correct. 

However, here’s what is new. I know many who have been going to bed with the Centers for Medicare & Medicaid Services (CMS) Inpatient Prospective Payment System (IPPS) 2020 Proposed Rule under their pillow, hoping osmosis would foster awareness of every key element. For those actively following reimbursement for the Social Determinants of Health (SDoH), however, page 300 holds the Holy Grail. On that page is an entry with vital fiscal considerations for every healthcare organization.

The ICD-10 code Z59.0, Homelessness, is being proposed in IPPS 2020 as a complication or comorbidity (CC). This coding for homelessness will be worth thousands of dollars, at a minimum, in additional reimbursement to organizations for Medicare patients. As shared by my esteemed colleague, Dr. Ronald Hirsch, in his Monday Rounds last month, “now that CMS has taken the first two steps, they still need to learn to walk by recognizing that many more social determinants influence the cost of care, and establishing them as (CCs) or a major complication or comorbidity (MCCs).” Truer words were never said. 

The Costs of Homelessness

Especially for my case management, coding, and physician advisor colleagues, you know exactly to what I’m referring. These are the patients who cost your organizations millions of dollars annually to manage. Patients with higher home instability risk are especially vulnerable; these persons experience risk of eviction or foreclosure, along with not being able to afford necessary utilities. They are 32 percent more likely to exceed the average length of hospitalization. According to the U.S. Department of Housing and Urban Development Point in Time Survey, 549,928 people are homeless in the U.S. on any given night, with 32 percent in unsheltered locations. Over 77,000 are chronically homeless. In California alone, homeless patients made about 100,000 visits to hospitals in a year, a 28 percent rise over the previous years. Lacking basic resources and support systems, these patients are five times more likely to be hospitalized in an inpatient unit, and stay on average four days longer in-house than other patients with the same diagnoses; that’s a cost of $2,000 to $4,000 per day.

Since Jan. 1 of this year, 12 hospitals and health systems have filed for bankruptsy. The causes include challenges with reimbursement and decreasing patient numbers: so much for the whole value versus volume focus. On the other hand, many entities have joined forces to directly address their population shifts and social determinants needs. In the first quarter of 2019 there were 27 mergers of hospitals and health systems. These collaborations have united key services for populations, enhancing care opportunities for those at risk, as defined by the SDoH, and otherwise. Some of these partnerships have saved institutions from closure. The partnership of the Center for Housing and Health and the University of Illinois Hospital saw healthcare costs fall as much as 60 percent.

Impact for the Future

To be honest, if CMS were to allow all the subcategories in Z59 to be coded as CCs, it would be a powerful financial boost to hospitals.

• Z59.0Homelessness
• Z59.1Inadequate housing
• Z59.2Discord with neighbors, lodgers, and landlord
• Z59.3Problems related to living in residential institution
• Z59.4Lack of adequate food and safe drinking water
• Z59.5Extreme poverty
• Z59.6Low income
• Z59.7Insufficient social insurance and welfare support
• Z59.8Other problems related to housing and economic circumstances
• Z59.9Problem related to housing and economic circumstances, unspecified

The need to ensure appropriate coding and reimbursement for those codes has been a popular headline this spring. The 23 new ICD-10 Z Codes proposed by the American Medical Association (AMA) and UnitedHealthcare address among the costliest issues to negatively impact hospitals, health systems, and other organizations. Notice that housing is listed as a potential new code for further expansion for this listing, as well as:

• Healthy food access
• Adequate housing
• Appropriate transportation
• Ability to pay for medications
• Ability to pay for utilities
• Caregiver needs

Areas also in desperate need of attention are food insecurity and transportation. Food insecurity-related healthcare costs in the United States are measured at $160.7 billion annually. Roughly 40 million adults lived in food-insecure households in 2017, with almost another 10 million people challenged to afford basic nutrition. Transportation issues force over 3 million patients annually to cancel, skip, or reschedule appointments with providers; the costs are estimated at upwards of $150 billion annually in healthcare consequences for patients and lost revenue in missed appointment time for providers. 

CMS Must Play Catch-up

CMS is already behind the curve, especially with a majority of managed care entities already reimbursing for and providing support to address housing, plus the full scope of SDoH. The healthcare industry can’t afford for CMS to fall even further behind by delaying approval of reimbursement for society’s most basic human needs. Hopefully, public comment and subsequent actions will yield the only logical response for the industry: allowing reimbursement by CMS for homelessness. Let this action serve as an important step for CMS to recognize the need for financial accountability and attention to the full spectrum of SDoH. Only then can hospitals, healthcare systems, and organizations achieve true financial sustainability for the future.