There is wide recognition that social determinants of health (SDOH) are significant drivers of health risks and outcomes and account for more than 60 percent of an individual's overall health. Recent research has recognized the importance of SDOH data and the necessity of collecting these data to empower providers to address health disparities. Despite this, the collection of SDOH data remains inconsistent.

Z codes are a set of reason codes within the ICD-10-CM introduced in 2015 to capture data on SDOH impacting the health of patients. Previous studies have documented higher rates of the top five chronic conditions (hypertension, depression, hyperlipidemia, rheumatoid arthritis, and chronic kidney disease) among Medicare fee-for-service (FFS) beneficiaries with reported Z codes compared to all Medicare FFS beneficiaries. Research has found use of Z codes to be low but highlighted the five most utilized Z codes (homelessness, disappearance/death of a family member, problems related to living alone, living in a residential institution, and relationship with spouse or partner), the five top provider types using these codes (family practice and internal medicine physicians, nurse practitioners, psychiatrists, and licensed clinical social workers) and, to a limited extent, differences in the use of Z codes across broadly-defined rural and urban areas.

We will examine 2019-2021 Medicare inpatient, outpatient, and carrier claims data to evaluate the use of Z codes by rural and urban providers to capture information on SDOHs affecting the health of rural Medicare FFS beneficiaries by age, gender, and rural residence across the rural continuum. We will interview key provider types from critical access hospitals and other rural and urban hospitals, rural health clinics, and federally qualified health clinics to understand opportunities to improve the use of Z codes by these providers.