Almost three centuries ago, a systemic classification for diseases was introduced by a French physician, François Boissier de Sauvages de Lacroix, to create an organized and standardized way of diagnosing and categorizing illnesses. Today, with the paradigm shift towards a more holistic healthcare system, the industry cannot afford to overlook Social Determinants of Health (SDOH) concerning the patients. This has now revolutionized traditional billing practices, with the induction of codes specifically tailored to support SDOH-related interventions and services. This evolution marks a new milestone in an approach towards a more equitable and effective healthcare delivery.
SDOH and the Evolution of Billing Codes
The introduction of codes for SDOH marks a major shift in an already established framework. According to the American Hospital Association, a 2021 report indicated that 88% of hospitals reported screening patients for social needs, yet only a quarter of them used this information in clinical care.
Billing codes, as it turns out, play a crucial role in health systems’ transition to care models addressing SDOH. For decades, any non-clinical interventions–making patients find housing or resolving food insecurity–had not been billable, which made it difficult for providers financially to invest that time on them. Today, however, this landscape is changing with the introduction of these new codes:
- Facilitate Full Care: New HCPCS codes such as G0136 will enable the service providers to be paid sufficiently for their time allocated to assessing SDOH factors, making such non-clinical needs part and parcel of the patient’s care plan.
- Promote Timely Interventions: SDOH codes improve the ability of health care providers to intervene early and address concerns before they get worse. This makes it possible for the providers to be reimbursed for their efforts in putting preventative measures in place following such an assessment.
- Providing Community Health Integration (CHI) services: In 2024, two new codes allow providers to report CHI services for providing additional support to patients who have unmet social determinants of health (SDOH) needs that significantly limit the treating physician’s ability to diagnose or treat the patient.
- New Codes, New Possibilities
In the past few years, several new codes, which are directly associated with SDOH have been introduced:
- ICD-10-CM “Z codes” (Z55 – Z65) to document social factors
- HCPCS G code 0136 for SDOH assessment and care planning
The ICD-10-CM “Z codes” (Z55 – Z65) were introduced to aid providers in recording non-medical factors that affect a patient’s health, particularly related to the social determinants of health. These factors include education, housing, employment and other environmental and social barriers.
- Z55: Problems related to education and literacy (e.g. illiteracy, lack of education and other problems related to health literacy etc.)
- Z56: Problems related to employment and unemployment (e.g. job loss, stressful work environments etc.)
- Z57: Occupational exposure to risk factors (occupational hazards viz. harmful substances/agents).
- Z58: Problems related to the physical environment (e.g. lack of housing with proper facilities).
- Z59: Problems related to housing and economic circumstances (e.g. homelessness and severe poverty).
- Z60: Problems related to social environment (e.g. living alone, socially excluded).
- Z62: Problems related to upbringing (e.g. childhood abuse, parental overprotection).
- Z63: Other problems related to the primary support group, including family circumstances (e.g. Problems in relationship with family members, absence of family members).
- Z64-65: Problems related to certain psychosocial circumstances (e.g. unwanted pregnancy, imprisonment, exposure to war).
According to a report by CMS titled, “Utilization of Z Codes for Social Determinants of Health among Medicare Fee-for-Service Beneficiaries, 2019”, out of the 33.1 million beneficiaries, around 1.59% had claims with Z codes in 2019 compared to 1.31% in 2016.
In 2024, CMS introduced the new HCPCS code, G0136, which will pay for administering an SDOH risk assessment.
G0136 “Administration of a standardized, evidence-based social determinants of health risk assessment tool, 5-15 minutes, not more often than every 6 months.”
The risk assessment is related to social factors of the patient, which will have an impact on the diagnosis and treatment of their medical conditions. In essence, it is a service that can be carried out in outpatient settings except for discharge visits. Here are a few instances when the code can be reported:
- The evaluation can be done on the same day an E/M service is rendered, except for the code 99211. During the comment period, CMS was questioned as to whether the patient using an on-line portal instead of having the service completed on the day an E/M service is conducted would qualify. They consider this as not a screening but more to be an assessment, and it is to be applied when the practitioner finds that the patient has unmet SDOH needs that interfere with the diagnosis or the treatment of an illness.
- G0136 can be billed with discharge visits from the hospital. For patients whose needs are not met, CMS expects that there will be follow-up visits as either outpatients or transitional care management visits, in an attempt to meet those needs.
- G0136 will be subject to cost sharing, (copay and deductible) unless it is performed at an Annual Wellness Visit (AWV).
CMS is also allowing G0316 to be provided on the same day as 90791 (psychiatric diagnostic evaluation) and with Health Behavior Assessment and Intervention codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168, when administered by a clinical psychologist, not a social worker.
Leverage the latest SDOH billing opportunities for improved care
SDOH ICD-10 Codes: Influence on Reimbursements
Another reason to apply SDOH ICD-10-CM diagnosis codes, besides the initiative for HHS Healthy People 2030 and being eligible to participate in the Inpatient Quality and Reporting Program, is that these applications may have implications on payment. For example, as of now, SDOH codes Z59.00 Homelessness unspecified, Z59.01 Sheltered homelessness, and Z59.02 Unsheltered homelessness all are found under Complications/Comorbidities (CC) in the MS-DRG system and are associated with an increase in reimbursements.
As an add-on to this, the following additional SDOH CCs were added into the final FY 2025 IPPS Rule applicable for October 1, 2024, as part of the given supplementation to the rule:
- Z59.10: Inadequate housing, unspecified
- Z59.11: Inadequate housing environmental temperature
- Z59.12: Inadequate housing utilities
- Z59.19: Other inadequate housing
- Z59.811: Housing instability, housed, with risk of homelessness
- Z59.812: Housing instability, housed, homelessness in past 12 months
- Z59.819: Housing instability, housed unspecified.
New Opportunities for Providers
Billing codes for SDOH services have introduced a wide variety of opportunities for healthcare providers:
- Increased Reimbursement: These new codes enable a direct financial incentive when providers address SDOH—as services were provided without pay, and now they can provide immediate reimbursement to providers, encouraging care incorporation into everyday health services.
- Codes for Telehealth: The new codes will also leverage the use of telehealth which will enable SDOH assessment even from a distance. This is beneficial for vulnerable populations, which include rural populations or those who lack any means of transportation.
- Strengthening Community Health Partnerships: Healthcare providers can collaborate very closely with community organizations to address patients’ social needs; that becomes billable through follow-up codes like G0019. This will create a better partnership between medical and social services.
Navigating Implementation Challenges
Despite the immense potential, there are several challenges the healthcare organizations face in the implementation of new codes:
- Education and Training on New Codes
- Integration of SDOH Assessments into Clinical Workflows
- Technology upgrades to support new codes
- Variability in reimbursement across payers
- Handling Privacy Concerns Regarding SDOH Data Collection.
A survey by the Healthcare Financial Management Association indicates that 65% of healthcare organizations pointed to staff training as the most arduous task in implementing SDOH.
Future Outlook of SDOH in Healthcare
The recent introduction of billing codes for Social Determinants of Health underlines a rather critical shift in health care delivery. Indeed, these represent much more than a whole shift of just paperwork; they also represent a critical shift in the way the health care system perceives and values comprehensive patient care.
As we look into the future, it will be important for the healthcare providers to crosswalk the screening tools or questions they use to gather information regarding social determinants w.r.t the medical codes available. Some groups have already started with this initiative, such as 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.
By encouraging the consideration of social factors in patient care, the healthcare system is brought one step closer to a holistic, patient-centered model that not only treats diseases but at the same time, reduces the root causes of health disparities.
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