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Billing and coding

How to use Z codes in mental healthcare

Text on a blue background: ICD-10 Z Codes

Z codes are an important tool for identifying the social needs of a patient population. Here’s how to leverage them effectively and compliantly.

Z codes are an important tool for identifying the social needs of a patient population. The data collected through Z codes — specifically social determinants of health (SDOH) codes — helps inform quality of care. This leads to more personalized, focused care and guides effective community partnerships that address the specific needs of its population.

What are ICD-10 Z codes?

Z codes are a section in the ICD-10 coding manual, listed under “Z00-Z99: Factors influencing health status and contact with health services.”

Overall, Z codes help indicate the reason for an encounter with a health service provider, especially when other ICD-10 categories can’t effectively capture the full circumstances leading to that patient’s need for care because the problem is distinct from a classifiable illness or injury.

What are SDOH codes?

As a specific subset of Z codes, social determinants of health (SDOH) codes are located in categories Z55 through Z65, and allow care interactions to be associated with socioeconomic and psychosocial factors.

“SDOH are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks,” according to the Center for Medicare & Medicaid Services.

SDOH-related Z codes allow for research and analysis at the system level to help organizations, providers, hospitals, health plans, and advisory boards to identify unmet social needs for patients and communities across the country.

Any health care provider can document their patient’s social needs by collecting SDOH data during any encounter, including intake assessments and regular mental health care sessions.

  • Z55: Problems related to education and literacy: Illiteracy, schooling unavailable, failed examinations, underachievement in a school, educational maladjustment, and discord with teachers and classmates.
  • Z56: Problems related to employment and unemployment: Unemployment, change of job, threat of job loss, stressful work schedule, and discord with boss and workmates.
  • Z57: Occupational exposure to risk factors: Exposure to noise, radiation, dust, other air contaminants, toxic agents, extreme temperature, and vibration.
  • Z58: Problems related to physical environment: Exposure to noise, air pollution, water pollution, soil pollution, radiation, tobacco smoke, as well as inadequate drinking-water supply.
  • Z59: Problems related to housing and economic circumstances: Homelessness, inadequate housing, discord with neighbors or landlord, problems related to living in a residential institution, lack of adequate food, extreme poverty, low income, and insufficient social insurance and welfare support.
  • Z60: Problems related to social environment: Problems of adjustment to lifecycle transitions, atypical parenting situation, living alone, acculturation difficulty, social exclusion and rejection, and being the target of perceived adverse discrimination and persecution.
  • Z61: Problems related to negative life events in childhood: Loss of love relationships, removal from home, altered pattern of family relationships, events resulting in loss of self-esteem, problems related to alleged sexual or physical abuse, and personal frightening experience in childhood.
  • Z62: Problems related to upbringing: Inadequate parental supervision and control, parental overprotection, institutional upbringing, hostility towards and scapegoating of child, and emotional neglect of child.
  • Z63: Other problems related to primary support group, including family circumstances: Problems in relationship with spouse or partner, problems in relationship with parents and in-laws, inadequate family support, absence of family member, disappearance and death of family member, disruption of family by separation and divorce, and dependent relative needing care at home.
  • Z64: Problems related to certain psychosocial circumstances: Problems related to unwanted pregnancy, problems related to multiparity, discord with counselors, and seeking and accepting interventions known to be hazardous and harmful.
  • Z65: Problems related to other psychosocial circumstances: Conviction in civil and criminal proceedings, imprisonment and other incarceration, problems related to release from prison, problems related to other legal circumstances (such as arrest, child custody proceedings, litigation and prosecution), victim of crime and terrorism, and exposure to disaster, war and other hostilities.

Can Z codes be listed as a primary code?

Z codes cannot be listed as a primary diagnosis for billing, in most cases, as Z codes distinctly refer to problems outside of illness or injury. In order to be eligible for reimbursement, insurance carriers require mental health care to meet a requirement for “medical necessity”, — a clinically appropriate service to treat a diagnosis of disorder, illness, or injury — which Z codes on their own do not meet.

Z codes can, however, be used along with a primary diagnosis code that describes the client’s specific disorder, illness, or injury in need of treatment. (For example, an F code related to the client’s presenting symptoms.) In this case, the Z code is recorded as an additional factor that helps inform the circumstances that led to the required care.

Following best practices for diagnosis and documentation means you’ll have fewer denials, and fewer requests for notes or additional information from insurance companies.

How do I determine which diagnosis is most appropriate when I’d normally use a Z code?

Often there are F codes that describe a set of symptoms and would accurately represent the clinical presentation for which you might have only used a Z code.

Only a licensed professional can recommend the appropriate F10-F99 diagnosis code for a mental, behavioral, or neurodevelopmental disorder. We’ve included a list of some commonly used secondary Z codes below, along with examples of primary diagnosis codes that have been used by other providers.

It’s important that you make a clear, accurate and specific diagnosis that is appropriate to your individual patient clinical picture. These examples should be for reference and are not intended to guide a diagnosis. The client must meet diagnostic criteria for the F code they are assigned. 

Z63.4: Disappearance and death of family member

For Z56.9 - Unspecified problems related to employment (includes Occupational Problems NOS):

For Z60.0 - Problems of adjustment to life-cycle transitions (includes Empty nest syndrome, Phase of life problem, Problem with adjustment to retirement)

For Z63.0 - Problems in relationship with spouse or partner (Relationship distress with spouse or intimate partner)

For Z63.4 - Disappearance and death of family member (Assumed death of a family member, Bereavement)

  • F43.21 Adjustment disorder, with depressed mood (up to 6 months)
  • F43.81: Prolonged grief disorder, complicated grief, complicated grief disorder, persistent bereavement disorder
  • F43.9: Reaction to severe stress, unspecified, trauma and stressor-related disorder, NOS, Unspecified trauma and stressor-related disorder
  • F43.0: Acute Stress Reaction, Acute Crisis Reaction, Acute Reaction to Stress

This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

Headway is a free service that makes it easier and more profitable for therapists and psychiatrists to accept insurance.

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