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Social Determinants of Health in Terminologies

 The World Health Organization (WHO) established the Commission on Social Determinants of Health (SDoH) in 2005. They define SDoH as “the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.” Some of these factors are food insecurity, housing, employment, transportation, social support, etc. While there is no universal agreement on a single definitive set of SDoH factors, there is at least a common understanding of them. As we continue to move toward a common definition, standard terminologies have already identified or created concepts that can be used to encode SDoH. 

As an example, ICD-10-CM has identified a subset of codes used to capture additional factors that influence a patient’s health. These encounter codes, Z codes, coincide with diagnostic or procedural codes being used in EHRs, and are acknowledged by CMS to be used as identifiers of SDoH.
There is a total of 97 current codes as of April 2020, under the following headers: ClayWorld400

  • Z55 Problems related to education and literacy
  • Z56 Problems related to employment and unemployment
  • Z57 Occupational exposure risk factors
  • Z59 Problems related to housing and economic circumstances
  • Z60 Problems related to social environment
  • Z62 Problems related to upbringing
  • Z63 Other problems related to primary support group, including family circumstances
  • Z64 Problems related to other psychosocial circumstances
  • Z65 Problems related to other psychosocial circumstances

Under these categories are granular codes used for billing and identifying specific factors
within these categories, e.g.:

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

Showing the continued expansion of SDoH, 20 new billable ICD-10-CM codes are proposed for implementation in October 2020:

  • Z55.5 Less than a high school degree
  • Z55.6 High school diploma or GED
  • Z56.83 Unemployed and seeking work
  • Z56.84 Unemployed but not seeking work
  • Z56.85 Employed part time or temporary
  • Z59.61 Unable to pay for prescriptions
  • Z59.62 Unable to pay for utilities
  • Z59.63 Unable to pay for medical care
  • Z59.64 Unable to pay for transportation for medical appointments or prescriptions
  • Z59.65 Unable to pay for phone
  • Z59.66 Unable to pay for adequate clothing
  • Z59.67 Unable to find or pay for child care
  • Z59.69 Unable to pay for other needed items
  • Z59.91 Worried about losing housing
  • Z60.81 Unable to deal with stress
  • Z60.82 Inadequate social interaction - limited to once or twice a week
  • Z60.83 Can hardly ever count on family and friends in times of trouble
  • Z60.84 Feeling unsafe in current location
  • Z60.85 Stressed quite a bit or very much
  • Z60.86 Stressed somewhat

Categorization of these codes is only the beginning of capturing SDoH in EHRs. The complexity of these risk factors in a patient requires the creation of additional codes, and for providers to use them. Recent research published by CMS reported that only 1.4% of Medicare beneficiaries had claims that included encounter codes, the most prevalent being Z59.0 Homelessness. With the increased attention on SDoH, CMS has pushed for the use of Z codes to establish more comprehensive EHR data collection that accounts for patient variables outside of the presenting medical problem.
As you perform terminology implementation or mapping work for your organization, we encourage you to keep SDoH in mind. Please promote the use of existing codes that correspond to SDoH and submit requests for new codes to standard developing organizations. We can all play a vital role in helping organizations throughout healthcare – state and federal agencies, payers, providers, EHR and analytics vendors, coding systems, and Information service companies – to recognize the critical need to address SDoH and create harmonization of data across settings, and to identify where each system intersects and their role in driving new methods for data collection. Please contact us if you need help submitting requests to standard developing organizations, need support with terminology implementation or mapping, or have other terminology topics that you’d like us to discuss.