Physician advisor's corner: Addressing health disparities with SDOH

CDI Journal - Volume 15, Issue 1

by Howard Rodenberg, MD, MPH, CCDS
In this issue of the CDI Journal, Angelica Naylor, MBA, BSN, RN, CCDS, has presented us with both an exploration of the problem of health disparities and a call to action (see p. X). The question that follows is how do we, both as individuals and as a collective of CDI professionals, respond to this challenge?

I’ve previously espoused that a purposeful focus on the social determinants of health (SDOH) is the best way we can help address the issue of health disparities. SDOH are those factors that influence health status beyond the simple presence of physical or mental illness. They include income level, educational achievement, food security, housing status, and social networking. Ensuring the SDOH are appropriately documented within the medical record allows us to capture the hard data needed to more clearly demonstrate the interactions of race, gender, ethnicity, and other key socioeconomic indicators with healthcare costs, utilization, and outcomes.

ICD-10-CM provides a means to document the SDOH using codes Z55–Z65. The Official Guidelines for Coding and Reporting note that codes within this series can be used for “persons with potential health hazards related to socioeconomic and psychosocial circumstances,” and that code assignment may be based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider. This is one of those rare exceptions where we don’t need the attending physician’s documentation for coding purposes.

A renewed interest in the SDOH within the medical record is not a unique idea. At the March 2019 ICD-10-CM Coordination and Maintenance Committee meeting, United HealthCare proposed an expanded list of Z codes to better define specific social determinants. The fiscal year 2020 inpatient prospective payment system (IPPS) proposed rule even suggested that code Z59.0, Homelessness, would qualify as a reimbursable comorbid condition. Neither proposition was adopted, but the groundwork for continued focus has been laid.

Our response to the challenges of recording the SDOH may occur on several levels. Individually, we can ensure that we look for the SDOH within the medical record in the course of our professional practice. We can educate our clinical and case management colleagues to include this information within their documentation, and we can ensure our coders are aware of this coding opportunity as well.

The institutional commitment to recording SDOH will require an infrastructure that promotes consistent mechanisms for information capture. Without routinely asking for this information, it is likely to be collected erratically, and when it is collected it may appear in various narratives in physician, nursing, or case management notes. This may cloud your ability to paint a reliable picture of your patient population.

Efficient and routine means of collecting SDOH data should be incorporated into physician, nursing, or care management templates. It would also be prudent to focus on specific, more objective Z codes that might be answered with a yes/no or by checking a box, in order to avoid difficulties of interpretation for more numerous subjective codes.

Your ACDIS Regulatory Committee has already begun to advance the SDOH agenda on a national level. This past October, we submitted a request for review of the severity levels (CC/MCC) of selected Z codes for inclusion within the FY 2022 IPPS proposed rule. We did so not only in recognition of how understanding SDOH can clarify health disparities, but also as a response to a contemporary focus on issues of social justice.

We considered that a deeper understanding of the SDOH can help drive efforts promoting fairness and equity within the healthcare system. We also felt that an analysis of the severity levels associated with specific SDOH may ensure that safety net hospitals are reimbursed appropriately for serving those most in need.

We have advocated for a severity level review of the following Z codes:

  • Z55.0, Illiteracy and low-level literacy
  • Z56.0, Unemployment
  • Z59.0, Homelessness
  • Z59.4, Lack of adequate food and safe drinking water
  • Z59.5, Extreme poverty
  • Z60.2, Problems related to living alone
  • Z65.1, Imprisonment and other incarceration

These codes have been chosen because of their relatively high frequency in demographic works, and because their more finite nature as essentially “yes/no” questions requires a minimum of interpretation.

We have also advocated for a reconsideration of the severity level for code R62.7, Adult failure to thrive, as this diagnosis is most often a reflection of SDOH, including poverty, living alone, and food insecurity. Like code Z59.0, Homelessness, this code was previously proposed for a severity level change from non-CC to CC in the FY 2020 IPPS proposed rule.

It’s clear that the impact of the SDOH will continue to be a target of public policy. As policymakers within our institutions and the directors of our CDI practices, it is incumbent upon us to lead the parade… or be left behind.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at or follow his personal blog at Opinions expressed are that of the author and do not necessarily represent those of ACDIS, HCPro, or any of its subsidiaries.

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