By Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM
The health care team is acutely aware that the hospital is the first and sometimes the last safety net patients use when community, family, and health plans fail them. Hospitals are unique in that they cannot deny access to care, nor should they, despite health plans and governmental decisions to deny payment. It is nonsensical for hospitals to carry this burden alone, but health care providers need to document the common reasons patients fail at home and find possible solutions.
Many patients continue to use the Emergency Department for their primary care. The social needs of patients can overwhelm busy physicians and frustrate hospital leaders as well as physician advisors as patients stay long beyond the DRG length of stay or extend their observation hours because they cannot leave the hospital safely for a myriad of reasons. Eligible patients may appeal their discharge under their Medicare rights because they do not want to leave the security of the institution. Many patients readmit to the ED or to acute care in less than 30 days because the social problems they face are not resolved and they return to the hospital. Fifty percent of readmissions are due to social issues. These include home and transportation instability (ASC Communications, 2020). It is necessary for the health care team to identify those social barriers and the possible causes.
Physician Advisors spend significant time educating colleagues on the value of excellent clinical documentation to reflect the clinical picture of the patient from admission to discharge. Physicians’ documentation details risk of mortality, affects the level of reimbursement, and justifies the need for specific post-acute care. Case managers can also contribute significantly in painting the patient’s story through documenting their Social Determinants of Health (SDOH).
CMS introduced Z codes in fiscal year 2016, as a method for hospitals to capture issues related to a patient’s socioeconomic condition. SDOH contribute to patients’ individual health, population health, and health care costs (Weeks, Cao, Lester, Weinstein, Morden, 2019). Studies demonstrate patients with a documented SDOH-related Z code suffer a higher proportion of chronic disease (Lee, MacLeod, Kuklina, Tong, Jackson, 2023). Understanding how the SDOH affect chronic disease prevalence in the ACO, or Health Plan allows the allocation of dollars to mitigate the actual factors contributing to chronic illness.
However, hospitals are slow to capture the valuable information that will translate into meaningful data. CMS reports health care providers used Z codes for 1.6% of Medicare fees for service beneficiaries in 2019 (AHA, Jan. 2022). Accurate documentation of social and economic patient factors allows the team to track and address risks for specific patient populations. Although the Z codes are not currently reimbursable, their use contributes to the picture of a hospital system’s value-based program and the inherent risk associated with the patient populations they serve. The aggregate data collected across populations can shape public health policy, influence reimbursement models, and target cities, counties, and states that can benefit from increased government or private funding.
The good news about the use of Z codes is that in 2018, CMS allowed non-physician team members, such as case managers and social workers to identify the SDOH, and through their written assessments support coding for the hospital (ASC Communications, 2020). A case manager can provide the necessary documentation to support the implementation of the codes, so it is not solely incumbent on the physician to provide the documentation or duplicate what the case manager documents. Hospital case managers expedite discharges, mitigate readmissions, and solve hefty social dilemmas for patients on a daily basis. They screen for social issues, health literacy, and medication adherence. The systematic collection of information case managers document in the assessment, plan, and discharge note paints the picture of the population in aggregate the hospital serves.
Case managers, like physicians, can learn clinical documentation integrity. They can accurately document a patient’s socioeconomic profile through targeted questions and motivational interviewing. Coders will also require the support of the hospital leadership to retrieve the necessary documentation from case managers and social workers and assign the appropriate Z codes.
The following is a list of ICD-10-CM codes retrievable from the case manager’s initial assessment and ongoing documentation.
Z59.1, Inadequate housing
Z59.5, Extreme poverty
Z75.1, Person awaiting admission to adequate facility elsewhere
Z75.3, Unavailability and inaccessibility of health-care facilities
Z75.4, Unavailability and inaccessibility of other helping agencies
Z76.2, Encounter for health supervision and care of other healthy infant and child
Z99.12, Encounter for respirator [ventilator] dependence during power failure
The codes reflect the reasons patients cannot be safely discharged, and reflect the discharge check-off lists used by many case managers while planning a discharge. Case managers should organize the discharge plan and the accompanying documentation to reflect what steps are in place to offset the barriers patients face.
Physician Advisors and hospital leadership can struggle with the questions, why do patients spend time at the hospital, when their medical issue is resolved and why do patients readmit so quickly? Hospital case managers know they contribute to the successful resolution of social and economic barriers for patients. Still, they may not have a method to quantify the value of their assessments and interventions.
Accurate and thorough documentation of a patient’s social and economic status and subsequently coded in the medical record, may provide an answer for both groups.
Citations: American Hospital Association. ICD-10- coding for Social Determinants of Health, Jan. (2022). https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf
Use of Z-Codes to Record Social Determinants of Health Among Fee-for-service Medicare Beneficiaries in Weeks, William B., et al. "Use of Z-codes to record social determinants of health among fee-for-service Medicare beneficiaries in 2017." Journal of general internal medicine 35 (2020): 952-955.2017 | SpringerLink
Jun Soo Lee PhD , Kara E. MacLeod DrPH , Elena V. Kuklina MD, PhD , Xin Tong MPH , Sandra L. Jackson PhD , Social Determinants of Health-Related Z Codes and Health Care Among Patients With Hypertension, AJPM Focus (2023), doi: https://doi.org/10.1016/j.focus.2023.100089
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Bio: Dr. Mary McLaughlin Davis is a Certified Case Manager, Clinical Nurse Specialist and former Senior Director for Case Management Cleveland Clinic Main Campus and Akron General Hospital. Currently she serves as project manager for Cleveland Clinic Case Management. Dr. McLaughlin Davis chairs the Advisory Board for ACPA and served as an Executive Board Member of The Case Management Society of America, from 2013 to 2019 and President from 2016 to 2018.