Addressing elderly readmission rates in the emergency department through coding social determinants of health

Older adults derive significant benefits from home or long-term care services; however, the critical impact of these environments on hospital readmission rates is frequently overlooked. It is essential to acknowledge the role of social determinants of health (SDoH) during emergency department (ED) visits. Nevertheless, there is often a deficiency in the documentation of these factors for older individuals. It is imperative to collect accurate coding data that reflects the frequency and risk factors associated with readmissions among diverse older adult populations to effectively reduce hospital readmissions, including through thoughtful capacity planning and strategic interventions.

A noteworthy development in this context is the introduction of Z codes for SDoH in the Tenth Revision of the International Classification of Diseases (ICD-10). This advancement presents a substantial opportunity to enhance the collection of SDoH data directly within the ED. However, there remains a lack of comprehensive understanding regarding their usage across all payers on a national level.

Healthcare providers utilize ICD-10-CM Z codes — specifically Z55 to Z65 — to capture SDoH and examine their relationship with readmission rates. These codes encompass a variety of significant social and economic factors, such as housing conditions, employment status, educational attainment and social environment. By identifying these potential SDoH, healthcare professionals can gain valuable insights into how these factors may influence a patient's health and contribute to their risk of readmission. These codes are subsequently linked to patient readmission data to more deeply explore the correlation between SDoH and readmission rates.

According to the ICD-10-CM Official Guidelines for Coding and Reporting, it is critical to document SDoH when this information is available. Importantly, this vital documentation is not solely the responsibility of physicians or healthcare providers; it can also include social factors gathered by other team members. In fact, front desk staff play a crucial role in collecting this information during patient check-in.

Medical coders are responsible for ensuring that SDoH are reported when they are:

• Documented by medical assistants, social workers, case managers or nurses in the official medical record
• Self-reported by the patient, with verification and inclusion in the medical record by a clinician or the patient's healthcare provider

SDoH can be recorded using ICD-10-CM Z codes when appropriately documented in the medical records, whether collected by clinical staff or self-reported by patients. A valuable approach to achieve this is by implementing a questionnaire that patients can complete while waiting or online prior to their appointment. This strategy empowers providers to identify and address any external factors impacting their patients' health outcomes. Numerous SDoH questionnaires are available online, or coders can develop customized versions.

Recognizing SDoH through coding enables healthcare providers to implement targeted interventions that address these crucial social needs, ultimately reducing the likelihood of readmission. Specifically, preventing readmissions for older adults hospitalized due to heart failure and sepsis is a priority for patients, clinicians, health systems and policymakers. Although Z codes represent substantial potential for hospitals to track SDoH, clarity regarding their frequency of use and their relationship to healthcare service consumption remains sought after.

Earlier this year, the Centers for Medicare & Medicaid Services (CMS) introduced a new code pertaining to patients' SDoH. HCPCS code G0136 is intended to remunerate clinicians for the time expended in assessing a patient's SDoH, which the care team may subsequently address either directly or through referrals. Although the implementation of G0136 has deviated somewhat from its original intent, the following information spells out its usage:

• HCPCS code G0136 authorizes clinicians to bill Medicare for performing a validated assessment of social needs that may influence the clinician's diagnosis or treatment of the patient. Examples of social determinants include income, education level, employment status, access to nutritious food, housing stability and neighborhood safety.
• The code, valued at 0.18 work relative value units (RVUs), is designated for the assessment of a patient's known or suspected social needs, rather than for SDoH screening.
• Despite the long-anticipated payment for SDoH assessment, the new code may have limited applicability due to its narrow definition.

Given the high costs associated with ED visits and the challenges of preventive care, understanding SDoH in relation to ED admissions could yield significant clinical and financial benefits. Notably, even after controlling other factors, SDoH Z codes demonstrated a connection to ED admissions. The documentation of a single SDoH Z code increased the likelihood of being admitted through the ED similar to having two or more comorbidities. This correlation suggests that screening tools and protocols may be more effectively implemented in the ED rather than during an inpatient stay or at discharge. Furthermore, the relationship between social and economic needs and ED admissions underscores the well-established link between inadequate access to preventive care and the utilization of low-value services.

There is considerable potential in the area of SDoH. By prioritizing these aspects of healthcare, we can work towards a future that ensures older adults receive the care and support necessary to thrive in their own homes or in long-term care settings. It is imperative that we collectively advance toward a more holistic approach in healthcare that acknowledges the significance of SDoH in fostering positive health outcomes.

Michael Malohifo’ou, RN, PhD, is a professional consultant for Solventum.