Palliative care, comfort care, and hospice care are terms often used in healthcare settings, sometimes interchangeably, yet they possess distinct meanings, particularly within the context of medical coding. As a crucial aspect of healthcare documentation and billing, understanding the nuances of coding for palliative care is essential for healthcare professionals, especially those in medical coding and clinical documentation integrity. This article aims to clarify the definition of palliative care, differentiate it from related terms, and provide a comprehensive guide to Coding Guidelines For Palliative Care, ensuring accuracy and compliance.
Defining Palliative Care: Beyond Comfort and Hospice
Often misunderstood as solely end-of-life care, palliative care is a specialized medical approach focused on enhancing the quality of life for individuals and their families facing serious illnesses. The National Institute on Aging (NIH), a division of the National Institutes of Health, defines palliative care as:
“Specialized medical care for people living with a serious illness, such as cancer or heart failure. Patients in palliative care may receive medical care for their symptoms, or palliative care, along with treatment intended to cure their serious illness. Palliative care is meant to enhance a person’s current care by focusing on quality of life for them and their family.”
This definition highlights a crucial point: palliative care is not exclusive to end-of-life situations. It can be administered alongside curative treatments, focusing on symptom management and improving patient and family well-being throughout the illness trajectory.
The Centers for Medicare & Medicaid Services (CMS) further elaborates on palliative care, defining it as:
“Palliative Care: Focuses on relief from physical suffering. The patient may be being treated for a disease or may be living with a chronic disease and may or may not be terminally ill.”
CMS emphasizes the holistic nature of palliative care, encompassing not just physical but also mental, social, and spiritual well-being. It is appropriate for patients at any stage of illness, from diagnosis onwards, and may include life-prolonging medications as part of the comprehensive care plan. This contrasts with hospice care, which, according to CMS, is:
- “Available to terminally ill Medicaid participants. Each State decides the length of the life expectancy a patient must have to receive hospice care under Medicaid.”
- “In some States it is up to 6 months; in other States, up to 12 months. Check with the State Medicaid agency if there are questions.”
- “Makes the patient comfortable and prepares the patient and the patient’s family for the patient’s end of life when it is determined treatment for the illness will no longer be pursued.”
- “Does not use life-prolonging medications.”
- “Relies on a family caregiver and a visiting hospice nurse. Is offered at a place the patient prefers such as in their home; in a nursing home; or, occasionally, in a hospital.”
Hospice care is specifically for terminally ill patients when curative treatment is no longer pursued, focusing on comfort and end-of-life preparation. It typically foregoes life-prolonging treatments and is heavily reliant on family and visiting nurses, often provided in home or hospice facilities.
Comfort care, as defined by NIH, is:
“Comfort Care is an essential part of medical care at the end of life. It is care that helps or soothes a person who is dying. The goals are to prevent or relieve suffering as much as possible and to improve quality of life while respecting the dying person’s wishes.”
Comfort care is often seen as a component within both palliative and hospice care, particularly at the end of life, emphasizing symptom relief and respecting patient preferences.
ICD-10-CM Coding for Palliative Care: Z51.5 and Beyond
In the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), the coding system used in the United States for diagnoses and inpatient procedures, “Palliative care” is indexed, directing coders to Z51.5 Encounter for Palliative Care. Notably, “Comfort Care” and “Hospice” are not directly indexed, although coding guidance exists to include them under palliative care coding in certain contexts.
Within the ICD-10-CM tabular list, the Z51 category instructions state, “Code also condition requiring care,” but there are no further specific instructions at the Z51.5 code level. This implies that when coding for palliative care, the underlying condition necessitating the care should also be coded to provide a complete clinical picture.
AHA Coding Clinic Guidance on Palliative Care Coding
The American Hospital Association (AHA) Coding Clinic, a respected industry resource for coding guidance, provides further clarification. The AHA Coding Clinic Q3 2010 states that “Comfort Care” and “End of life care” should be coded to Encounter for Palliative Care (Z51.5). This guidance reinforces the broader application of Z51.5 to encompass related concepts like comfort care and end-of-life care within the coding framework.
Several AHA Coding Clinics address palliative care coding, offering valuable insights:
- AHA Coding Clinic, 1996, Q4, page 47
- AHA Coding Clinic, 1998, Q1, page 11
- AHA Coding Clinic, 2008, Q3, page 13
- AHA Coding Clinic, 2010, Q3, page 18
- AHA Coding Clinic 2017, Q1, page 48
- AHA Coding Clinic 2020, Q4, page 98
- AHA Coding Clinic 2022, Q1, page 18
Reviewing these Coding Clinics is crucial for a comprehensive understanding of evolving coding practices related to palliative care and related services.
POA Exemption for Z51.5
Effective October 1, 2021, with the FY2022 coding updates, the Centers for Disease Control and Prevention (CDC) and its National Center for Health Statistics added code Z51.5 Encounter for Palliative Care to the list of diagnoses exempt from Present on Admission (POA) reporting. This exemption means that whether palliative care was present on admission or developed during the hospital stay does not need to be reported separately.
Ensuring Accurate Coding: Documentation and Initiation of Care
Accurate coding for palliative care requires careful review of medical documentation. It’s essential to confirm that palliative care services have actually commenced during the encounter before assigning the Z51.5 code. Documentation might indicate an order for palliative care, but if services are not initiated during the stay, the code should not be assigned.
To ensure accurate and consistent coding, healthcare facilities should foster clear communication between coding staff and palliative care teams. Discussions should focus on what constitutes adequate documentation and where this documentation will be routinely located within the patient’s health record.
Coding “Do Not Resuscitate” (DNR): Z66
Another vital code in conjunction with palliative care and end-of-life discussions is Z66 Do Not Resuscitate. This code, indexed under “DNR” in ICD-10-CM, captures the patient’s decision to forgo cardiopulmonary resuscitation (CPR). The tabular list for Z66 includes “DNR status” as an inclusion term, further defining its scope.
Documenting a patient’s DNR status is critical for ethical and clinical reasons. Often, hospitals utilize specific forms, commonly referred to as “DNR” orders, to formally document the patient’s wishes. This documentation informs medical professionals not to initiate CPR in the event of cardiac or respiratory arrest.
Impact of Z66 on Quality Metrics
The Z66 code can significantly impact quality scoring algorithms and healthcare metrics. In mortality reviews and quality of care studies, hospitals often exclude cases with a Z66 code, especially in instances of in-hospital deaths. This exclusion is crucial for accurately interpreting mortality data and assessing the quality of care, as deaths in patients with DNR orders are often anticipated and managed according to patient wishes.
Addressing Post-Acute Care Placement Delays: Z75.1
Challenges in discharging patients to post-acute care facilities, such as skilled nursing facilities or rehabilitation centers, are increasingly common. These delays can extend hospital length of stay (LOS). In such instances, Z75.1 Person awaiting admission to adequate facility elsewhere becomes a relevant code to consider.
This Z code can be valuable for capturing the complexities of patient discharge processes and resource constraints within the healthcare system. While no official coding guidelines or AHA Coding Clinic guidance specifically addresses Z75.1 in this context, its use can provide valuable data for internal analysis and potentially for external reporting.
Utilizing Z75.1 for Data Analysis
Hospitals are encouraged to proactively utilize Z75.1 when appropriate and analyze the data generated by its use. Running reports on Z75.1 usage over time and examining the LOS for cases with this code can reveal patterns and contribute to process improvement initiatives. Comparing the average LOS for MS-DRGs (Medicare Severity Diagnosis Related Groups) with and without Z75.1 can highlight cases where discharge delays are contributing to extended stays.
Engaging clinical documentation integrity (CDI) and coding staff in discussions regarding Z75.1 is essential. Reviewing case management and discharge planning documentation can help identify cases where Z75.1 is applicable. This proactive approach to coding and data analysis can provide valuable insights into hospital operations and patient flow.
The Importance of Accurate Data: CMS MedPAR and Beyond
Accurate coding and data submission are paramount for healthcare organizations. CMS MedPAR data, which utilizes principal and secondary diagnosis codes from hospital claims, relies on the accuracy of coded data. Ensuring that accurate coded data is submitted to CMS and other relevant databases (e.g., state-level databases) is vital for reliable healthcare reporting.
This data informs analyses of patient care, mortality, quality outcomes, and future healthcare needs at local, regional, and national levels. Accurate coding of palliative care, DNR status, and facility placement issues contributes to a more comprehensive and reliable picture of healthcare delivery and patient experiences.
References:
Hospice vs. Palliative Care: What’s the Difference? | VITAS Healthcare
https://www.nia.nih.gov/health/what-are-palliative-care-and-hospice-care
Palliative Care vs. Hospice Care Similar but Different (cms.gov)
