ICD-10 adds more detail on the social determinants of health

November 16th, 2016 / By Paul LaBrec

The requirement by the Centers for Medicare and Medicaid Services (CMS) last fall to begin coding healthcare claims for reimbursement using the International Classification of Diseases-Tenth Revision (ICD-10) has greatly expanded the number and specificity of codes available to describe healthcare encounters. Among these new codes are hundreds that describe supplemental factors and additional detail related to the healthcare encounter, similar to the supplemental “V” and “E” codes used in ICD-9. 

In the ICD-10 classification scheme, Z Codes are found in Chapter 21, “Factors influencing health status and contact with health services (Z00-Z99).” Among these new “Z” codes is the following series related to potential hazards due to family and social circumstances impacting health status:

Z55-Z65 – Persons with potential health hazards related to socioeconomic and psychosocial circumstances1

Z55 – Problems related to education and literacy
Z56 – Problems related to employment and unemployment
Z57 – Occupational exposure to 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 certain psychosocial circumstances
Z65 – Problems related to other psychosocial circumstances

Each of these codes has sub-codes providing a more specific description of the problem.  Some of these codes describe issues traditionally recognized as related to socioeconomic status:

Z59 – Problems related to housing and economic circumstances
Z59.0 – Homelessness
Z59.1 – Inadequate housing
Z59.4 – Lack of adequate food and safe drinking water
Z59.5 – Extreme poverty
Z59.6 – Low income
Z59.7 – Insufficient social insurance and welfare support

While others are not traditional measures of social factors:

Z60.2 – Problems related to living alone
Z60.3 – Acculturation difficulty
Z60.5 – Target of (perceived) adverse discrimination and persecution
Z63.1 – Problems in relationship with in-laws
Z62.1 – Parental overprotection

As I discussed in a previous blog the measurement and application of social determinants of health in population health management and payment reform has gained increasing interest and importance in recent years.  The inclusion of Z Codes in administrative claims data now allows direct analysis of aspects of the patient’s social environment alongside demographic and clinical factors, and both can be related to utilization and financial outcomes.

In the November 2016 issue of Health Affairs, Gottlieb and colleagues suggest four ways in which data on social determinants of health collected through Z codes may be used to inform population health initiatives.

  • Improving panel management – supplementing traditional clinical data for patient management
  • Expanding the definition of quality improvement – to include activities such as food access intervention
  • Staffing for team-based care – to include staff such as social workers to help patients secure adequate housing or other social services
  • Adjusting provider panel sizes – to account for additional time necessary to address the special needs of patients with certain social situations impacting their health

In discussing the potential benefits for increased collection and use of social determinants data, the authors cite the success of “e codes”—patient injury data collected by hospitals—in identifying population needs for interventions such drowning prevention, firearm safety and bicycle injury prevention, as an example of the public health benefits that can be gained through such data collection, aggregation and analysis. The authors from Health Affairs conclude that:

“Identifying a clear process for collecting and aggregating data on social determinants of health is an important next step towards transforming health care, refining value-based payment, and ultimately influencing both health- and non-health-sector strategies to improve population health.”

Our Clinical and Economic Research team at 3M has created a composite index of social determinants of health defined at a Census Tract level using state-specific analysis of U.S. Census data.  We can link these standardize scores based on geography to the geocoded addresses of patients.  With the advent of ICD-10 we will be investigating socioeconomic factors as revealed in Z codes on claims with socioeconomic status as defined in Census data.  Stay tuned.

Paul LaBrec is research director for Populations and Payment Solutions with 3M Health Information Systems.


1 ICD-10 Data.com. “Factors influencing health status and contact with health services Z00-Z99.” Accessed November 15, 2016 at http://www.icd10data.com/ICD10CM/Codes/Z00-Z99