Written by Brieanne Lyda-McDonald
As social determinants of health are recognized as a driving factor in people’s health status and outcomes, providers have looked for ways to document these issues. When the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) went into effect in 2015, it brought new opportunities to code for social determinants using “z-codes”. These codes use broad categories to identify family and social circumstances that may impact a patient’s health status (see table below). However, after several years, research has shown that these z-codes are not commonly used. Until 2018 medical coders were limited in the codes they could list by physician documentation. Social determinants screening results and background information are more commonly gathered by case managers, discharge planners, social workers, and nurses. Effective February 2018, coders are now allowed to use documentation from these other professionals caring for patients to support the use of the social determinant z-codes. In outpatient settings, where physicians often designate ICD-10 codes themselves, they are less likely to use these z-codes because there is currently little effect on billing and reimbursement. However, as z-codes become integrated into payment and risk adjustment models, there will be more incentive for using these codes.
More recently, a partnership between the American Medical Association and UnitedHealthcare developed an additional 23 codes that would allow for more specific identification of social needs and risk factors.
These new codes would include things like whether an individual has less than a high school degree, if they are unemployed and seeking work, if they are unable to pay for prescriptions or transportation, and inability to deal with stress.  A 60-day public comment period for the new codes ended on May 10, and the Centers for Disease Control and Prevention will likely not announce if the codes are approved until early next year. If approved, they would take effect October 1, 2020. 
Medical coding for social determinants has the benefit of systematically documenting the external factors that may impact a patient’s health and create challenges in their interactions with the health care system or barriers to obtaining recommended treatments. In the future, these codes can be used as part of payment calculations and risk-adjustment for payments that providers receive. As we look to the future, it will be important to help providers crosswalk the screening tools or questions they use to gather information about social determinants with the medical codes that are available. Some groups have started to do this work, such as the federal Health Information and Technology, Evaluation and Quality Center (HITEQ), which has created a crosswalk between the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) and z-codes.  With the coming adoption of the state’s standardized screening questions, developed by the North Carolina Department of Health and Human Services, such a crosswalk may be a useful tool to support providers as they integrate the responses to questions into their medical coding.