Skip to Main Content

ICD-10-CM Z Codes: Enhanced Payment for Social Determinants of Health (SDOH) Bill Above Program

Date: 09/23/24

Sunshine Health thanks providers for all you do to help keep our Medicaid members healthy and ensure they receive assistance for their Social Determinants of Health (SDOH). To show our appreciation for your efforts, Sunshine Health is offering additional reimbursement to providers who submit detailed claims or encounters using Social Determinant of Health (SDOH) ICD-10-CM Z Codes.

This SDOH incentive takes effect February 1, 2025.

Z Codes represent factors that influence health status and any contact with health services that may be recorded as diagnoses. Codes Z-55 through Z-65 identify non-medical factors that may influence a member’s health. To learn more about benefits and barriers to utilizing Z Codes, we encourage providers to reference this Quick Guide to SDOH ICD-10 Codes (PDF).

Enhanced Payment

Sunshine Health is offering Enhanced Payment to all providers who bill for an assessment. The results can be positive or negative, but positive results should include procedures codes for interventions. It’s important for members to be screened at every visit. The incentive will be reimbursed two times per year as follows.

  • $20 for reporting a positive SDOH screening and referral along with appropriate Z Code for pregnant enrollees
    • Diagnosis code(s) on the claim should indicate member is pregnant
    • Providers should include the “TH” modifier when billing, which is required when submitting claims for pregnant members
    • Providers should also file a Notice of Pregnancy (NOP) whenever they diagnose a member as pregnant via the member’s account in the Secure Provider Portal
    • Referrals to Case Management can also be done through the member’s account in the Secure Provider Portal
  • $10 Provider incentive for reporting a positive SDOH screening and referral along with the appropriate Z Codes for enrollees
  • $10 Provider incentive for reporting a negative SDOH screening along with the appropriate Z Codes for enrollees
  • Claims will be adjudicated and paid as they are billed

Providers should report these screenings by billing the appropriate CPT codes below to indicate food, housing and/or transportation insecurities. The best practice is for providers to ask the member if they have recently received a screening. Providers should use one of the two G codes below to indicate the screening was performed and to indicate the outcome:

  • Screening Performed and Negative: G9920
  • Screening Performed and Positive and Provision of Recommendations: G9919

Code Intervention Categories

This list is subject to revisions and additions to improve alignment with SDOH data elements. The approved CPT codes to be used for billing are:

  • Food Insecurities: 96160
  • Housing Instability: 96156
  • Transportation Insecurity: 96161

Please Note

Our Enhanced Payment Program is in addition to the compensation arrangement set forth in your participation agreement in our provider network, as well as any other Sunshine Health incentive program in which you may participate.

Questions?

If you have any questions, please call Sunshine Health Provider Services at 1-844-477-8313 or visit the Secure Provider Portal. Our Provider Engagement staff are also here to help answer questions. Visit the Find Your Account Manager tool to confirm the individual supporting your specialty and region. We encourage you stay up to date on Sunshine Health provider notices by reviewing and bookmarking Provider News.

SH_7990