Physician perspectives on Z codes for social determinants of health screening

BACKGROUND: Health settings are increasingly assessing and addressing health-related social needs. ICD-10 Z codes are billing codes for social determinants of health (SDOH), but represent a novel opportunity to document social needs given their ubiquity; yet they are seldom used. Little work has explored physician perspectives on the utility of Z codes for social needs documentation. OBJECTIVE: To elucidate physician understandings of Z codes and their perspectives on Z codes' utility in documenting patients' health-related social needs. 

DESIGN: Semi-structured qualitative interviews. 

PARTICIPANTS: Physicians at high Z-coding hospitals in New Jersey (n = 18). 

APPROACH: Deductive and inductive thematic content and cross-case analysis. 

KEY RESULTS: Physicians assessed social needs. History taking and physician specialty influenced when needs were identified and documented. Needs most often came up in discharge planning. Physicians recognized their important role in ensuring social needs would be documented, but were unsure of what to do when a patient identified these needs. Physicians lacked explicit knowledge about Z codes and often would accidentally use them by "diagnosing" health-related social needs in the problem list. Hospital systems, SDOH screening, and reimbursement all influenced Z-coding; participants could not describe a systematic screening or documentation process at any hospital. Ultimately, Z codes were viewed as a tool to connote complexity and seek higher reimbursement. 

CONCLUSIONS: Z codes are ubiquitous across electronic medical records and represent an opportunity to document health-related social needs across settings. Physicians reported using them primarily as billing codes to document complex medical planning in the context of social risk and to drive higher reimbursement. Future work could consider these codes for other initiatives, such as integrating them into screening practices or using this reimbursement to fund social health programs.