Latest News: IPPS and the Social Determinants of Health

CMS, in its IPPS proposed rule, is asking for comments about SDoH codes.

There has been so much going on in the world of the social determinants of health (SDoH) over the last two weeks. Quoted from our Centers for Medicare & Medicaid Services (CMS) Administrator, who is rocking and rolling with press releases, Chiquita Brooks-LaSure explained in one that “Advancing health equity is the core work of (CMS). We can’t achieve our health system goals until everyone can attain the highest level of health.” 

I am sure I will be talking about her more as we cover the additional releases in the coming weeks. However, for the purposes of this article we are going to focus on the Inpatient Prospective Payment System (IPPS) release and open period for discussion related to the SDoH.

CMS is exploring how and if modifications need to be made to SDoH codes Z55-Z65, and how they may be able to improve their ability to recognize severity of illness, complexity of service, and/or utilization of resources under the MS-DRG system.

Specifically, CMS is looking at its connection to complication and comorbidity (CC)/major CC (CC/MCC) capture and the impact on hospital resource utilization. CMS is evaluating how improvements in documentation can lead to more accurate reporting for diagnosis codes describing the social and economic circumstances of our patients, in an effort to support the advancement of health equity – as well as improvements in data collection, nationally, regionally, and within hospitals and health systems, as an easy means to obtain relevant SDoH data on patient populations.

Recommendations are being made to capitalize on the Z codes, to look at internal health disparities, as well as health equity issues across the care continuum, impacting discharge planning and post-acute transfers.   

Consider the efforts that have been in place with the expansion of the Z codes in October 2021 and the clarification of clinician documentation to include details in the electronic medical record (EMR) from healthcare professionals. I would hope that coders are pulling in the great initial assessments from case management, which highlight many of the SDoH details that impact patient progression and transitions of care from the hospital setting.

However, CMS and I am concerned, which is why I am sure this is the impetus for the comment-and-question period. Because in 2019, CMS reported that Z codes for SDoH were only found on 1.59 percent of inpatient claims. And I get it; they are not required, and it is likely an extra step to find this information in the medical record.

Add to that the notion that many coders are overwhelmed by demands of quick turnaround for production, so claims can get out the door, with an ethical focus just on getting the diagnoses accurate. The ask for something else that is not required, and often not documented in the physician notes, which currently does not provide extra reimbursement for the health system, often falls to the bottom of the list of mounting priorities. I understand the apathy, but something needs to change to encourage greater utilization of the codes and therefore, CMS is requesting suggestions. Time to offer your advice and expertise.

So today I ask, are the SDoH Z codes being coded at your health system, to the best of your knowledge? To see the results from listeners during this week’s Monitor Mondays click here.

Programming Note: Listen to Tiffany Ferguson’s live reports on the social determinants of health every Monday on Monitor Mondays, 10 Eastern.