[topline] In response to Senate Bill 23-174, HCPF proposed Z codes as diagnoses on claims for kids < 21.  This is contrary to how the law is written and puts us in a position to investigate kids, without knowing what will happen with the info.  

Fill out this short HCPF form to get updates about this crucial benefit:

https://lp.constantcontactpages.com/sl/dsfoVtI

A stakeholder meeting is Nov 17, 2023 12:30 PM, go this this page to register
https://hcpf.colorado.gov/sb23-174-coverage-policy

COMBINE supported SB23-174 which allows us to treat people under 21 who are enrolled in Medicaid without a dx.  Originally this was intended for children who met some threshold for ACEs but HCPF countered with "[evaluating each client for ACEs is too complex and would be expensive for us to make a process to determine who gets care and who doesn't, and since ALL these kids are poor, they probably have some ACEs, so let's just allow them to get care, since they are already in the RAEs, so it's all already covered.]"

The law is in effect (since Aug 6), and COMBINE clinics are using the diagnosis of Unhappiness (R45.2), which is a covered diagnosis, basically because claims won't process without a dx.  Claims are getting paid with this and we have had no trouble. 

"SECTION 2. Act subject to petition - effective date. This act takes effect ... on Sunday, August 6, 2023."

Here's the text of the law
  https://leg.colorado.gov/sites/default/files/2023a_174_signed.pdf 

of note: "THE STATE DEPARTMENT SHALL PROVIDE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE WITH ACCESS TO LIMITED SERVICES WITHOUT REQUIRING A DIAGNOSIS."

A report due on Nov 1 of each year is also mandated in the law. "THE CONTENTS OF
THE REPORT MUST BE DETERMINED THROUGH THE STAKEHOLDER PROCESS
DESCRIBED IN SUBSECTION (4) OF THIS SECTION. AT A MINIMUM, THE REPORT
MUST INCLUDE DATA ON THE UTILIZATION OF SERVICES, BY CODE..."

Here's the list of codes they consider to be covered by this law.  No surprises here. These are the usual psychotherapy codes. 

Now comes HCPF with a plan and a request for stakeholders to comment on the plan. 

Here's what they are providing as information about Z codes: 

https://hcpf.colorado.gov/sites/hcpf/files/CMS_2023_OMH_Z_Code_Resource.pdf

Some of the codes seem innocuous for example : • Z59.86 – Financial insecurity 

This is true just by them being an enrolled member of Medicaid. 

This may actually be a fairer description than our current solution which is the covered dx R45.2 "Unhappiness."

However, an equity argument could be made for these z-codes. 

See   https://thegravityproject.net/

read https://medium.com/@mcallahanlyft/if-we-cant-measure-a-problem-how-can-we-fix-it-creating-better-data-to-address-sdoh-3b052a925aab

Some talking points: 

1) The Z codes do not have criteria.  For example Z58.6 "Inadequate drinking-water supply" has no criteria for how to assess whether Z58.6 is an applicable code.  Most of the Z codes in the SDOH range (Z55-65) are essentially arbitrary and rely on observers to make subjective assessments.

2) There is no chance that data collection will have statistical qualities of reliability or validity.  Reliability refers to the consistency of a measure, ensuring that repeated assessments yield similar results. Validity delves into the accuracy of a measure, ascertaining whether it truly captures the intended construct.

Providers will not have the same standards for which to measure the Z code, as their life experience and ideas about poverty, standards of living, quality of life, and parenting are subjective.  Interrater reliability will be very low and a child may be assessed as having multiple relevant Z codes by one provider and less by another.  

3) Because the primary concern is billing for claims, providers will want to provide Z codes sufficient for the claim, which will probably be a single code.  For many children, multiple codes will apply.  Providers will be inconsistent in which code they provide on the claim.

4) Collecting data that is actionable is appreciated, however there is no evidence that HCPF or other organizations will take action on this data, and therefore there isn't support for requiring this data.  The data will be noisy, with no real relationship from client to client or provider to provider.  

5) Since Z55-65 represents a wide range of social determinants of health, requiring Z codes puts providers in an inappropriate position to assess children on a myriad of axes, such as parenting interactions, housing, food security, and access to clean water.  This is all out of the scope of mental health providers to assess.  We are not trained to recognize when these situations are problems or not.  It is inappropriate to put us in a role where we're required to assess beyond our scope.  

6) The law states that a diagnosis is not required.  HCPF for unstated reasons is going beyond what the law was intended to do.  If HCPF would like to collect Z codes for child (or any) Medicaid members it is entirely possible to do this through other efforts, such as the BHA CCAR effort, which is currently under re-design.

Here's the list: 

Z55 – Problems related to education and literacy
• Z55.5 – Less than a high school diploma (Added, Oct. 1, 2021)
• Z55.6 – Problems related to health literacy
Z56 – Problems related to employment and unemployment
Z57 – Occupational exposure to risk factors
Z58 – Problems related to physical environment (Added, Oct. 1, 2021)
• Z58.6 – Inadequate drinking-water supply (Added, Oct. 1, 2021)
• Z58.8 – Other problems related to physical environment
• Z58.81 – Basic services unavailable in physical environment
• Z58.89 – Other problems related to physical environment
Z59 – Problems related to housing and economic circumstances
• Z59.0 – Homelessness (Updated)
• Z59.00 – Homelessness unspecified (Added, Oct. 1, 2021)
• Z59.01 – Sheltered homelessness (Added, Oct. 1, 2021)
• Z59.02 – Unsheltered homelessness (Added, Oct. 1, 2021)
• Z59.1 – Inadequate Housing (Updated)
• Z59.10 – Inadequate housing, unspecified
• Z59.11 – Inadequate housing environmental temperature
• Z59.12 – Inadequate housing utilities
• Z59.19 – Other inadequate housing
• Z59.4 – Lack of adequate food (Updated)
• Z59.41 – Food insecurity (Added, Oct. 1, 2021)
• Z59.48 – Other specified lack of adequate food (Added, Oct. 1, 2021)
• Z59.8 – Other problems related to housing and economic circumstances (Updated)
• Z59.81 – Housing instability, housed (Added, Oct. 1, 2021)
• Z59.811 – Housing instability, housed, with risk of homelessness (Added,
Oct. 1, 2021)
• Z59.812 – Housing instability, housed, homelessness in past 12 months
(Added, Oct. 1, 2021)
• Z59.819 – Housing instability, housed unspecified (Added, Oct. 1, 2021)
• Z59.82 – Transportation insecurity (Added, Oct. 1, 2022)
• Z59.86 – Financial insecurity (Added, Oct. 1, 2022)
• Z59.87 – Material hardship due to limited financial resources, not elsewhere classified
(Added, Oct. 1, 2022; Revised, April 1, 2023)
• Z59.89 – Other problems related to housing and economic circumstances (Added,
Oct. 1, 2021)
Z60 – Problems related to social environment
Z62 – Problems related to upbringing
• Z62.2 – Upbringing away from parents
• Z62.23 – Child in custody of non-parental relative (Added, Oct. 1, 2023)
• Z62.24 – Child in custody of non-relative guardian (Added, Oct. 1, 2023)
• Z62.8 – Other specified problems related to upbringing (Updated)
• Z62.81 – Personal history of abuse in childhood
• Z62.814 – Personal history of child financial abuse
• Z62.815 – Personal history of intimate partner abuse in childhood
• Z62.82 – Parent-child conflict
• Z62.823 – Parent-step child conflict (Added, Oct. 1, 2023)
• Z62.83 – Non-parental relative or guardian-child conflict (Added Oct. 1, 2023)
• Z62.831 – Non-parental relative-child conflict (Added Oct. 1, 2023)
• Z62.832 – Non-relative guardian-child conflict (Added Oct. 1, 2023)
• Z62.833 – Group home staff-child conflict (Added Oct. 1, 2023)
• Z62.89 – Other specified problems related to upbringing
• Z62.892 – Runaway [from current living environment] (Added Oct. 1, 2023)
Z63 – Other problems related to primary support group, including family circumstances
Z64 – Problems related to certain psychosocial circumstance
Z65 – Problems related to other psychosocial circumstances