To help improve the collection of the social determinants of health (SDoH) Z codes, the Centers for Medicare & Medicaid Services (CMS) Office of Minority Health last week released a new Z code infographic.
The goal of this was to assist providers with understanding and using SDoH terminology in their documentation that will allow for greater alignment for ICD-10-CM Z code capture. As discussed, CMS believes that greater Z code capture will enhance quality improvement activities and provide further insights into the existing health inequities that hospitals and their community are facing.
The infographic clarifies that Z codes can be captured and utilized in any health setting and by any provider as a tool for identifying the nine major categories that the Z codes represent, such as employment, housing, literacy, food insecurity, personal safety, and transportation. Reporting of Z codes would be for social factors that influence an individual’s health status, condition, or the reasons for receiving health services that are not classifiable elsewhere as diseases, injuries, or external causes. The infographic does clarify that SDoH information can be collected prior to, during, or after a health care encounter through structured assessments and/or screening tools. However, the codes should only be assigned when the documentation specifies that the patient has an associated problem or risk factor that is influencing the patient’s health. Coding professionals can utilize documentation from social workers, community health workers, case managers, or nurses if the information is in the medical record. SDoH can also be self-reported if it is signed off by a licensed professional and in the medical record.
I would like to provide an example: Patient X has come into their primary care office visit for a ‘cough that won’t go away.’ During the visit, patient X is provided paperwork to complete and sign as part of registration. When the medical assistant calls the patient back to the exam room, the patient discusses that they are unable to complete the paperwork because they have trouble with reading the material.
The medical assistant is understanding and listens to patients’ concerns related to their limited reading level and then proceeds to help patient X fill out the paperwork. Issues related to health literacy is documented in the patient’s record so the rest of the care team understands that this patient will be unable to read any materials that are printed at the end of their visit or during subsequent visits. At time of coding, the new code Z55.6 ‘problems related to health literacy’ are captured and reported.
CMS is continuing to offer outreach materials to increase the use of Z code capture and clearly has stressed that this is a valuable means for identifying, reporting, and analyzing how social determinants impact patients’ health.
The Centers for Medicare & Medicaid Services (CMS) released in its 2025 Outpatient Prospective Payment System (OPPS) Final Rule a new Conditions of Participation (CoPs)
Coding in the post-acute care world has taken on a new significance in the past five years. For those of us who are coders, this
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