Developing Story: CMS Recognizes Homeless as a CC

This week and next, I plan to expand on thoughts about the 2024 Inpatient Prospective Payment System (IPPS) rule regarding health equity and the social determinants of health (SDoH). For today’s article, I will focus on the specific call for homelessness diagnosis codes. That is z-code 59.00, 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.   

Making a distinction between the sheltered and unsheltered subcategories, which were added in 2021, helps specify if a homeless individual has some access to community resources, versus those who do not. A sheltered homeless person may be admitted to the hospital, but have the ability to discharge to a shelter or have access to a medical bed at the shelter, which would allow them to receive care from nursing staff (and potentially, the ability to remain in the shelter during the day). An unsheltered individual may be living out of their car or sleeping on sidewalks. Such an individual may not have access to showers or a secure location to place their belongings or medications, posing additional risk and complexities to their care needs. 

The final rule acknowledges the value of the SDoH, and has also recognized the low utilization of z-codes, currently sitting at 1.59 percent of all claims, from recent reports. To increase z-code utilization, the Centers for Medicare & Medicaid Services (CMS) has stated that “consistent with our annual updates to account for changes in resource consumption, treatment patterns, and the clinical characteristics of patients, (we are) recognizing homelessness as an indicator of increased resource utilization in the acute inpatient hospital setting.”

I commend the subcommittee that worked on this with CMS, particularly acknowledging the impact of homelessness on increased length of stay, delays related to denials from post-acute providers, poor access to outpatient care to manage chronic conditions, greater presence of and exposure to communicable diseases, and the significant presence of substance abuse and mental illness.

CMS fully recognizes the underreporting of SDoH z-codes; however, they are hoping and expecting the new quality requirements for the Hospital Inpatient Quality Reporting Program (IQR), titled Social Drivers of Health, will yield higher reporting of z-codes in the coming years. CMS has stated that z-code reporting will continue to be considered for future analysis in CC capture, similar to homelessness. So, I ask our readers, when applicable, to ensure that they are creating mechanisms in their healthcare organizations for z-code capture. 

For further details, please check out the now on-demand webcast from last week, during which Marie and I presented on the SDoH and the new requirements as well. Likewise, feel free to reach out to me directly if you have further questions regarding how this can be implemented in your healthcare organization.

Programming note: Listen to Tiffany Ferguson’s live reporting on the social determinants of health (SDoH) every Tuesday, 10 Eastern, on Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer.

References:

FY 2024 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Proposed Rule – CMS-1785-P | CMS