Using ICD-10 Z Codes to Identify Social Drivers of Health

While social drivers of health (SDOH) may not be on everyone’s mind, SDOH is a key project for the CDC. In fact, in the Office of the Assistant Secretary of Health (OASH), Healthy People 2030, SDOH, and health equity and literacy are the three major areas of focus. The five key areas of SDOH are health care access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment. 

World Health Organization (WHO) research shows that social determinants can play a bigger role than health care or lifestyle choices in overall health. Numerous studies suggest that SDOH accounts for between 30% and 55% of health outcomes. 

Despite this emphasis by the CDC and WHO, only 1.9% of inpatient hospital admissions have SDOH Z codes, the ICD-10 coding tool for socioeconomic and psychosocial factors.

Understanding Social Drivers of Health

The WHO defines Social Drivers of Health as “the conditions in which people are born, grown, work, live, and age, and the broader set of forces and systems shaping the conditions of daily life.” Factors that influence these conditions include economic policies, development agendas, social norms, and political systems.

Medical care alone cannot address all of the factors influencing patient health. Poverty stands out as an enormous driver of health, impacting access to housing, services, education, and transportation. However, gender is also a strong determinant of health. Women have higher costs of care than men due to their overall use of health services. At the same time, they are more likely than men to be poor, unemployed, or working in an environment that does not provide health care benefits.

ICD-10 Z Codes Framework

Within the ICD-10-CM, the US version of the Internation Classification of Diseases 10^th Revision, framework, Z codes have been designed to document social and environmental factors influencing health status. These are found in Chapter 21 (Z55 – Z65). Reporting these codes aids in justifying medical necessity, painting a complete picture of the patient’s diagnosis and treatment, and identifying potential barriers to diagnosis and treatment. Furthermore, they are also used to gather data on treatment efficacy and the true cost of care.

Documentation Sources

These codes can be documented via several sources, such as clinical staff observations, patient self-reported information, and social worker and case manager assessments. 

Key Z-Code Categories

Education and Literacy (Z55)

This category covers many situations, including illiteracy, unavailable schooling, having less than a high school diploma, and discord with teachers and classmates.

New code: Z55.6 Problems related to health literacy was added this year due to the recognition that many patients have difficulty understanding health-related information, medication instructions, and completing medical forms.

Employment and Occupation (Z56)

Unemployment, job changes, threats of job loss, and military deployment fit under this heading. However, stressful job situations, such as difficult work colleagues and sexual harassment, are also included here. 

Exposure to Risk Factors (Z57)

This category includes occupational risk exposures such as noise, radiation, environmental tobacco smoke, and toxic agents in agriculture and other industries. Exposure to COVID-19 can also be coded in this category.

Problems Related to Physical Environment (Z58)

Initially, the main item under this heading was inadequate drinking water supply (Z58.6) and/or safe drinking water. In 2024, two new codes were added:

            Z58.8 Other Problems related to physical environment

             Z58.81 Basic services unavailable in physical environment

              Z58.89 Other problems related to physical environment

Housing and Economic Circumstances (Z59)

While Z58 refers specifically to the physical environment, Z59 covers topics such as homelessness, inadequate housing, discord with neighbors and landlords, inadequate food, extreme poverty, and insufficient social support. New codes added in 2024:

            Z59.1 Inadequate housing

              Z59.10 Inadequate housing, unspecified

                Z59.11 Inadequate housing environmental temperature

                Z59.12 Inadequate housing utilities

                Z59.19 Other inadequate housing

Problems Related to Social Environment (Z60)

Adjustments to life-cycle transitions, living alone, adapting to a new culture, and social isolation and exclusion are part of the social environment coding.

Problems Related to Upbringing (Z62) 

Problems with parental supervision, upbringing away from parents, and personal history of abuse or neglect in childhood comprise the bulk of the items in this category.

In 2024, there was a further expansion for reporting child-guardian relationships:

Z62.23 (Child in custody of nonparental relative)

Z62.24 (Child in custody of nonrelative guardian)

Z62.823 (Parent-step child conflict)

Z62.83- (nonparental relative or guardian-child conflict)

Z62.831 (nonparental relative-child conflict)

Z62.832 (nonrelative guardian-child conflict)

Z62.833 (Group home staff-child conflict)

Z62.892 (Runaway (from current living environment))

Other codes added for specifying abuse history include:

Z62.814 Personal history of child financial abuse

Z62.815 Personal history of intimate partner abuse in childhood

Other Problems Related to Primary Support

In contrast to the codes for upbringing, these focus on the absence of various family members, whether due to divorce or death. It also includes caring for a dependent relative at home and other stressors such as military deployment and addiction in a family member.

Problems Related to Certain Psychosocial Circumstances (Z64)

At present, the three conditions listed for Z64 are problems related to unwanted pregnancy, issues related to multiparity, and discord with counselors.

Problems Related to Other Psychosocial Circumstances (Z65)

Conviction, imprisonment, release from prison, and problems with other legal circumstances cover one aspect of this category. Additionally, being a victim of crime or terrorism or exposure to disaster, war, and other hostilities is also included.

How to Use Z Codes in Your Practice

The codes in categories Z55 – Z65 should only be reported as secondary diagnoses per the ICD-10. These codes can be reported, “based on medical record documentation from clinicians involved in the care of the patient who are not the patient’s provider.” Since this information is social data and not medical diagnoses, the guidelines allow other providers’ input to be used for reporting.

The CMS suggests the following process to document SDOH codes.

1. Collect SDOH data: As mentioned above, this data may be gathered from various providers, including community health workers, case managers, and self-reported questionnaires.
2. Document SDOH data: The data can be documented via patient history, diagnosis list, or provider notes. Even if the data gathered cannot be coded with the current list, it should be included in the notes.
3. Map SDOH data to Z codes: Coding, billing, and EHR systems can all help locate the appropriate Z code.
4. Data analysis: Using the data gathered, analysis can help improve health care in your facility and access to services in your community. Referrals can be made to social services, providers, and organizations to support your patients.
5. Reporting SDOH findings: The SDOH data can be used in reports to administration, including boards of directors. 

The guidelines include an example of how these codes can be used in a clinical visit:

 “A patient who lives alone may suffer an acute injury temporarily impacting their ability to perform routine activities of daily living. When documented as such, this would support assignment of code Z60.2: Problems related to living alone. However, merely living alone, without documentation of a risk or unmet need for assistance at home, would not support assignment of code Z60.2.”

Screening Tools for Collecting SDOH Data

Gathering the necessary SDOH may seem overwhelming or cumbersome at the beginning, but it is important to remember some essential tasks. First, educate your staff on the need to screen, document, and code each patient’s data. Second, ask patients about their SDOH needs. They may not know how to discuss nonmedical issues, so they may need prompting.

In terms of prompting patient information, there are several screening tools available. The Agency for Healthcare Research and Quality (AHRQ) suggests these five screening tools:

• HealthBegins Upstream Risks Screening Tool  (PDF) includes questions about 14 SDOH
• WellRx is a validated 11-item clinical screener for nonmedical social needs
• Kaiser Permanente’s Your Current Life Situation (YCLS) survey  (PDF) captures a range of social and economic needs, including living situation, housing, food, utilities, child care, debts, medical needs, transportation, stress, and social isolation
• Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE)  includes 17 core and four optional SDOH questions. Its tool kit comprises the four electronic health record (EHR) tools, technical resources, best practices, multiple tested workflows, and other resources.
• OCHIN’s EHR-based SDOH Data Collection, Summary, and Referral Tools (PDF)

There are some other screening tools available as well, like the following.

• The AHC Health-Related Social Needs Screening Tool: This tool is meant to be self-administered and addresses housing instability, food insecurity, transportation needs, utility needs, and interpersonal safety.
• American Academy of Family Physicians: This screening tool is available in English and Spanish as part of The EveryONE Project. The short form includes 11 questions about housing, food, transportation, utilities, personal safety, and the need for assistance. It can be self-administered or administered by clinical or nonclinical staff.

SDOH in 2025 and beyond

SDOH screening became mandatory for hospital inpatients in 2024. As of 2025, it is expected to become mandatory in outpatient settings, including hospitals, ambulatory surgical centers, and rural emergency hospitals. The Centers for Medicare & Medicaid Services (CMS) will require voluntary reporting in 2025 and transition to mandatory reporting in 2026. 

What do you need to know about SDOH screening in 2025?

• Focus on outpatient settings: CMS is expanding SDOH screenings beyond inpatient care to include outpatient settings, aiming to identify and address social needs across healthcare encounters. 
• Voluntary reporting phase: In 2025, reporting SDOH screening data will initially be voluntary, allowing healthcare providers to familiarize themselves with the process. 
• Mandatory reporting in 2026: CMS will require mandatory reporting of SDOH screening data from outpatient settings. 

Social Drivers of Health: A Team Effort

Many healthcare providers may balk at the idea of “one more thing” added to their already busy workflow, so gathering SDOH data should be a team-based effort integrated into the practice’s workflows. Large practices may have care coordinators or patient navigators to handle these tasks, while smaller practices might rely on nurses, medical assistants, and other support staff.

In addition to managing the workflow to adopt additional screening, developing a list of referral resources to connect patients to needed services will be crucial. While the process may seem daunting, numerous resources are available to assist with its development and continued use. Adding screening and coordinating services to meet social needs may reduce physician and staff burnout as health improves in communities where barriers have previously existed.