ICD-10-CM April 2023 Update: 42 New Codes for Social Needs and Financial Abuse

Until recently, ICD-10-CM changed once a year on October 1, and everyone planned around it. NCHS now also releases an update on April 1, and this year's is the first April update big enough to break something. Effective for encounters on or after April 1, 2023, there are 42 new diagnosis codes, seven deletions and one revision. If your EHR, your claim scrubber or your clearinghouse has not loaded them, a code that was valid on March 31 may reject on April 3.

Most of the additions fall into two groups, and both are about things that happen to patients outside the exam room: health-related social needs, and abuse, including a new category of financial abuse. A third, smaller group splits the old noncompliance codes by reason. Here is what changed, what to update, and why we think the Z codes deserve more attention than their reimbursement suggests.

Key takeaways

• 42 new codes, 7 deletions and 1 revision take effect for dates of service on or after April 1, 2023. Codes apply by date of service, so a March 30 visit cannot carry a new code.
• Z59.1 (inadequate housing) is deleted and replaced by Z59.10 to Z59.19. Any favorites list or screening template that still carries Z59.1 will produce an invalid code from April 1.
• Z91.14 and Z91.15 (noncompliance with medication and with dialysis) are deleted and replaced by codes that state the reason, including financial hardship.
• Twelve new T74 and T76 codes describe confirmed and suspected financial abuse of adults and children; the Y07 perpetrator codes now distinguish current from former partners and add relationships.
• Social needs Z codes rarely change payment, but MIPS, Medicaid contracts and PCMH reporting depend on them, and the guidelines allow them to be assigned from any clinician's documentation or patient self-report.

Group one: health-related social needs

The Z55 to Z65 range covers problems related to socioeconomic and psychosocial circumstances. The October 2022 update had already added Z59.82 (transportation insecurity), Z59.86 (financial insecurity) and Z59.87 (material hardship). The April update expands Z59.1 (inadequate housing) into fifth-character codes, adds a health literacy code and two environment codes, and revises the title of Z59.87 to "material hardship due to limited financial resources, not elsewhere classified".

The noncompliance split matters more than it looks. "Noncompliant with medication" has been a judgment written into charts for decades. "Noncompliant due to financial hardship" is a different statement: it names a cause the practice can act on, through a formulary change, a manufacturer program or a social work referral, and it is a cause a payer's care management team can see on the claim.

Group two: abuse, and the new financial abuse codes

Chapter 19 gains twelve codes in the T74 (confirmed) and T76 (suspected) series for adult and child financial abuse: T74.A1 and T74.A2 for confirmed, T76.A1 and T76.A2 for suspected, each with the usual seventh character for initial encounter (A), subsequent encounter (D) or sequela (S). Chapter 21 adds matching history codes: Z62.814 and Z62.815 for a history of child financial abuse and of intimate partner abuse in childhood, and Z91.413 and Z91.414 for an adult history of financial abuse and intimate partner abuse.

Chapter 20 revises the Y07 perpetrator series. The old Y07.01 to Y07.04 (husband, wife, male partner, female partner) are deleted and replaced by codes that distinguish current from former partners and add a non-binary partner, and new codes cover additional family relationships. These codes matter most in geriatrics, pediatrics and emergency medicine, and in any practice that participates in adult protective services reporting. They will rarely change payment. They will change what the record says, and that is their purpose. If your practice screens for elder abuse, the financial abuse codes finally give a place to record the most common form of it.

Why Z codes matter more than they pay

Z codes for social needs are not paid on their own. They almost never move a claim's reimbursement, and they do not count in the Medicare Advantage risk adjustment model. So practices ask us why they should bother. Three reasons, in order of how quickly they matter:

1. Quality programs are asking for them. The 2023 MIPS quality measure set includes a new measure, Quality ID 487, Screening for Social Drivers of Health, and several Medicaid managed care contracts and accountable care arrangements now pay for or require social needs screening. The Z code is the evidence that the screening produced a finding, and it is the field every report can filter on.
2. PCMH and care management depend on them. A patient with Z59.82 (transportation insecurity) is a patient who will no-show the follow-up. Practices working toward or maintaining PCMH recognition need a way to identify these patients for care management, and the diagnosis code does that without a separate registry.
3. Medical necessity arguments. A telehealth visit, a home visit or a longer visit is easier to justify on appeal when the record shows the reason the patient could not come in or could not follow the plan.

One useful documentation rule: per the ICD-10-CM Official Guidelines, social determinant codes can be assigned from documentation by any clinician involved in the patient's care, including social workers, nurses and case managers, and from patient self-reported information that a clinician has incorporated into the record. The physician does not have to write it in the note. A completed screening tool that the medical assistant enters is enough, as long as the finding is documented as relevant to the encounter.

A worked example

A fictional 71-year-old patient with heart failure comes in for a follow-up after a hospital stay. The medical assistant's screening shows the patient has been skipping the diuretic to stretch the prescription and missed the cardiology appointment because the bus route changed. The physician adjusts the regimen and the care manager arranges transportation and a lower-cost alternative. The claim carries I50.22 (chronic systolic heart failure) first, then Z91.141 (noncompliance with medication regimen due to financial hardship) and Z59.82 (transportation insecurity). Coded that way, the patient appears on the care management list, the transitional care work is easier to defend, and the practice's social needs screening measure has a documented finding. Coded as I50.22 alone, all of that work is invisible.

Four systems to update this week

1. EHR code set. Confirm with your vendor that the April 1 code set is loaded. Most cloud EHRs did this automatically; some on-premise systems need a manual update. Test by searching for Z59.11 and Z91.141.
2. Favorites lists and templates. Anywhere Z59.1, Z91.14 or Z91.15 appears in a pick list or a social needs template, replace it with the specific new code. Providers will keep clicking the old one until it is gone.
3. Claim scrubber and clearinghouse. Confirm both accept the new codes and reject the deleted ones. A scrubber that still allows Z59.1 lets a claim through to a payer that will deny it.
4. Screening tool mapping. If you use a standardized social needs screener (PRAPARE, the AHC HRSN tool, or your own), map each positive response to the current codes so the code is suggested automatically.

The mistakes we expect to see

Using the new codes before April 1. Codes apply by date of service; a March 30 visit cannot carry Z59.11. Coding a social need that was screened but not addressed; the guidelines are clear that the code represents a problem documented as relevant to the encounter, not a survey answer that nobody read. And the reverse, which is more common: screening every patient, filing the results and coding nothing, which means all that work is invisible to every quality report.

One more: putting a Z code first. A claim whose only or primary diagnosis is a Z55 to Z65 code will usually deny for medical necessity, because the visit needs a clinical reason. The medical diagnosis leads; the social need follows.

Questions we hear

Do payers reject claims that have only Z codes?

Usually, yes, for medical necessity. Put the medical diagnosis first and the social need code after it. The order matters to payers even when it does not matter to the guidelines.

Is there a new set of codes for the October 2023 update too?

Yes, the fiscal year 2024 update takes effect October 1, 2023 and NCHS has published the proposed additions, but they are not final until the summer. Plan for a second update this year. The April cycle is here to stay, so the code set review should now happen twice a year.

Where can our staff learn the social needs coding rules properly?

The Official Guidelines section on Chapter 21 is short and readable, and our coding courses walk through the SDOH section with sample screening results. Practices in care gap programs with Revelrex get the screening-to-code mapping built into their monthly gap reports.

What to do this week

1. Search the EHR for Z59.11 and Z91.141. If they are not found, open a ticket with the vendor today.
2. Export every diagnosis favorites list and template and replace Z59.1, Z91.14 and Z91.15 with the new codes.
3. Send one test claim with a new code through the scrubber and clearinghouse and confirm it passes; send one with Z59.1 and confirm it is stopped.
4. Map your social needs screening tool's positive responses to the current Z codes and give the medical assistants the crosswalk.
5. Pull April 1 to April 5 claims for any deleted code and correct them before they deny.