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February 13, 2020

Are providers documenting social determinants? Not really, CMS says.

Daily Briefing

    Providers increasingly are focusing on social determinants of health (SDOHs) as a way to improve their patients' outcomes, but a recent CMS report suggests providers have been slow to adopt new SDOH-related claims codes.

    Cheat sheet: What you need to know about social determinants of health (SDH) data

    Report details

    The Z codes are a subset of ICD-10 codes, created in 2016, that are designed to capture "factors that influence health status and contact with health services." To gauge how providers are using the Z codes, CMS analyzed Medicare fee-for-service (FFS) claims and enrollment data for 2016 and 2017.


    CMS found that, in 2016, providers used Z codes to document SDOHs for a total of 446,171 FFS Medicare beneficiaries. That number increased by 4.7% in 2017, with providers documenting SDOHs for 467,136 Medicare beneficiaries.

    But despite that progress, CMS noted that overall SDOH documentation was low. According to CMS, just 1.4% of Medicare's 33 million FFS beneficiaries had claims with SDOH Z codes in 2017. CMS found that providers in 2017 most commonly used the Z codes to document when patients were homeless, experienced problems related to living alone, experienced problems related to psychosocial circumstances, experienced problems in a relationship with a partner or spouse, or had a family member disappear or die.

    CMS in the report also noted that patients with documented SDOHs were likely to have chronic health conditions. According to CMS, 73% of such patients had hypertension, 53% had depression, 38% had chronic kidney disease, 34% had diabetes, and 25% had congestive heart failure. Further, CMS found that 25% of the patients with Z codes were dually eligible for both Medicare and Medicaid.

    CMS flags barriers that could be keeping providers from using SDOH Z codes

    CMS in the report highlighted several barriers to more widespread use of the Z codes.

    For example, CMS said many providers are unaware of the codes or are confused about whether they're able to use them. According to Home Health Care News, some providers are not aware that clinicians who aren't a patients' primary care provider may use the codes to document a SDOH.

    Further, CMS said although providers are screening for and capturing data on SDOHs, "this captured information is not consistently translated to standardized data." That's because the health care industry hasn't yet developed industry-wide technical specifications for screening and documenting SDOHs, CMS said.

    CMS said documentation of SDOH codes likely would improve across care settings if there were improvements in educating providers and medical coders about the Z codes, as well as a reduction in reliance on clinicians to capture SDOHs.

    And CMS added increasing use of the codes is important. "[M]ore widely adopted and consistent documentation is needed to more comprehensively identify social needs, and monitor progress in addressing them," the report stated. "SDOH data collection can lead to an increase in patient referrals to supportive services and help identify population-level trends that have both health and cost implications."

    Experts say report paints an incomplete picture of SDOHs

    While some experts applauded CMS for releasing the report, they also cautioned that the report might not accurately reflect the prevalence of SDOHs among Medicare beneficiaries—or providers' use of Z codes to document them.

    According to Inside Health Policy, Michael Adelberg, David Ault, and Tricia Beckman in a client alert from the law firm Faegre Baker Daniels noted that the report is based on data from 2017, and said providers' use of the Z codes likely has changed since then. In addition, they noted that CMS didn't include data on Medicare Advantage beneficiaries in its analysis, Inside Health Policy reports.

    Separately, Jamo Rubin, president of Signify Community, said there's a disconnect between providers and social services, which might make it difficult for providers to accurately determine whether SDOHs are affecting their patients. Further, Rubin said the Z codes are developed from a medical standpoint and not a social one, so they might lack the context needed to give providers an accurate view of a patients social circumstances.

    Still, Rubin said, "Any reinforcement of [SDOHs] from America's biggest buyer of health care is helpful to advance the maturation of SDOH as a legitimate piece of the health care puzzle" (Slabodkin, Health Data Management, 1/26; Muchmore, Healthcare Dive, 1/30; Cirruzzo, Inside Health Policy, 2/3 [subscription required]; Holly, Home Health Care News, 1/30).

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