Risk adjustment models, like the Hierarchical Condition Category (HCC) model, are essential in healthcare for predicting patient costs and outcomes. However, a frequent criticism is their limited scope. These models often overlook crucial factors significantly impacting a patient’s overall health: health-related social needs. The challenge lies in effectively incorporating these social determinants of health into risk adjustment calculations due to data capture complexities. While some advancements utilize area deprivation or social deprivation indices, these often lack individual patient-level specificity when it comes to Hcc Diagnosis Code applications in broader risk assessment.
The Role of Z Codes in Capturing Social Determinants
To address the gap in individual-level data regarding social factors, healthcare is increasingly turning to Z codes. These ICD-10-CM diagnosis codes are designed to capture various factors influencing a patient’s health status. Specifically, the Z55-Z65 subset of Z codes focuses on documenting potential health risks stemming from socioeconomic and psychosocial circumstances. The interaction between Z codes and existing risk adjustment models, including those utilizing hcc diagnosis code frameworks, is still evolving. Currently, Z codes do not carry HCC values. Despite this, a growing number of payers are mandating the reporting of Z codes by healthcare practices to gain a more comprehensive understanding of patient risk.
Social determinants of health Z codes are categorized as follows within the ICD-10-CM system:
- Z55 – Problems Related to Education and Literacy
- Z56 – Problems Related to Employment and Unemployment
- Z57 – Occupational Exposure to Risk Factors
- Z58 – Problems Related to Physical Environment
- 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
It is important to note that Z codes within the Z55-Z65 range cannot be used as a primary diagnosis. Their purpose is supplementary, providing context to the primary hcc diagnosis code and other reported conditions. Z code assignments can be based on patient self-reported information or data gathered by clinicians. However, to ensure data integrity and clinical relevance, all Z code documentation must be reviewed, authenticated, and integrated into the patient’s medical record by a physician or qualified healthcare professional. This process ensures that social determinants, alongside traditional medical diagnoses reflected in hcc diagnosis code assignments, contribute to a more holistic view of patient health and risk.
