Pulmonology Coding Alert

2022 ICD-10-CM Z code revisions focus on housing insecurity, food insecurity, and more.

You’ll find many of the new diagnosis codes that go into effect on October 1, 2021 in Chapter 21: Factors Influencing Health Status and Contact With Health Services of the ICD-10-CM manual. These codes allow you to document the Social Determinants of Health (SDOH) — the social circumstances that can affect a patient’s health — in exceptional detail.

Making a regular practice of documenting SDOH with the patients in your practice could prove to be worth the time and effort when the physician is crafting a care plan. Learn what to expect from next year’s ICD-10-CM Z code changes and how they might benefit your pulmonology practice.

Choose From These Codes for Housing Insecurity

The Centers for Disease Control and Prevention (CDC) has added a number of new codes to the existing Z59.- (Problems related to housing and economic circumstances) codes to continue to facilitate documentation of SDOH.

Code Z59.0 (Homelessness) has been converted to a parent and now requires a 5th character for greater specificity. The three codes you’ll use to document homelessness include:

• Z59.00 (Homelessness unspecified)
• Z59.01 (Sheltered homelessness), which the code’s synonyms tell you to use when a patient is “living in a shelter such as: motel, scattered site housing, temporary or transitional living situation” and
• Z59.02 (Unsheltered homelessness), which you will use for patients “residing in [a] place not meant for human habitation such as: abandoned buildings, cars, parks, sidewalk” or “residing on the street.”

Additionally, “the CDC has broken out Z59.8 (Other problems related to housing and economic circumstances) into a number of new codes. You will now be able to document when a patient’s health is affected by housing instability, but the patient is currently not homeless, by adding 6th characters to Z59.81- (Housing instability, housed),” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

You will now also be able to report:

• 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)

Synonyms for all the Z59.81 codes tell you that you can use them when a patient is dealing with problems due to a foreclosure on home loan, is past due on rent or mortgage, and/or has undergone multiple unwanted moves in the last 12 months. The CDC has moved similar synonyms (“foreclosure on loan,” “isolated dwelling,” and “problems with creditors,”) that were originally assigned to what is now parent code Z59.8 to new code Z59.89 (Other problems related to housing and economic circumstances).

Go In-Depth With These Food Insecurity Codes

The CDC has added two new codes to the Z59.4- (Lack of adequate food) code set, which address the health determinants based on lack of, or lack of access to, food. You’ll use Z59.41 (Food insecurity) when you come across documentation that indicates lowered food intake or eating schedules that are interrupted. The U.S. Department of Agriculture defines food insecurity as, “food intake of household members is reduced and their normal eating patterns are disrupted because the household lacks money and other resources for food” (URL: www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/definitions-of-food-security.aspx).

Additionally, Z59.48 (Other specified lack of adequate food) is accompanied by synonyms such as “inadequate food” and “lack of food,” so you can be on the lookout for that verbiage in the physician’s notes.

“Parent code Z59.4 gets a name change from ‘Lack of adequate food and safe drinking water’ to ‘Lack of adequate food’ with the synonym ‘Inadequate drinking water supply’ deleted. But to address that issue, you’ll have a new code, Z58.6 (Inadequate drinking-water supply), which is accompanied by the synonym ‘Lack of safe drinking water,’” Moore notes.

Exclusion Note: The Excludes1 codes for the Z59.4- codes documenting effects of hunger (T73.0), inappropriate diet or eating habits (Z72.4), and malnutrition (E40-E46) will become Excludes2 codes, with deprivation of food (T73.0) added to the list.

Understanding How SDOH Can Affect a Pulmonologist’s Care Plan

Scenario: A patient comes in to see the pulmonologist one month after their initial visit. The patient was originally diagnosed with acute COPD, but the symptoms have worsened. At the end of the first visit, the physician prescribed a new medicine for the patient. During the follow-up visit, the pulmonologist asks if the patient has noticed any change in their symptoms while taking the new prescription. The patient replies that they have not been taking the new prescription because their insurance will not cover it and the out-of-pocket cost is too high.

If the provider had documented the patient’s financial hardship (Z59.9 Problem related to housing and economic circumstances, unspecified) during the initial visit, they may have been able to address the treatment plan to better accommodate the situation. “The care plan may be affected by the Social Determinant of Health, which could increase the overall complexity of patient management,” says Carol Pohlig, BSN, RN, CPC, ACS, senior coding and education specialist at the Hospital of the University of Pennsylvania. Now, the physician needs to manage a patient with worsening conditions and financial hardship.

Remember: The SDOH factor must directly impact the plan of the provider who is caring for the patient. In this scenario, the pulmonologist may have found a different prescription that would be covered by the patient’s insurance or with a lower out-of-pocket cost. When the care providers document the Social Determinants of Health, then the pulmonologist can draft a care plan that takes the SDOH into account, so the patient can receive the care they need that suits their situation. As a new element in Medical Decision Making for 2021 Office Visits, SDOH corresponds to a moderate risk with respect to patient management.

Stay Up to Date on the New Z-Code Guidelines

The CDC has also updated and revised the guidelines on how to document SDOH findings. You’ll find the following guidelines under Section I.C.21.b of the ICD-10-CM Official Guidelines for Coding and Reporting, “Codes describing social determinants of health (SDOH) should be assigned when this information is documented.”

If the patient experiencing potentially hazardous health conditions that relate to their socioeconomic or psychological circumstances, you may assign codes based on the medical record documentation from clinicians who are not the patient’s provider, as this information constitutes social information.

This suggests you may use “documentation of social information from social workers, community health workers, case managers, or nurses, if their documentation is included in the official medical record.” You are also allowed to assign codes to self-reported SDOH as long as a provider or clinician approves the information and incorporates it into the medical record.