Palliative care, comfort care, and hospice care – these terms are often used interchangeably, causing confusion in healthcare settings. While related, they carry distinct meanings, especially when it comes to medical coding and documentation. For those involved in medical coding, clinical documentation integrity, and healthcare administration, understanding the nuances of palliative care coding is crucial for accurate data reporting and patient care management. This article clarifies the definitions, explores ICD-10-CM coding for palliative care, and highlights key codes relevant to this vital aspect of patient care.
Defining Palliative Care, Comfort Care, and Hospice
To accurately approach Coding Palliative Care, it’s essential to differentiate it from comfort care and hospice care. Leading healthcare authorities provide clear definitions:
The National Institute on Aging (NIH) 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 emphasizes that palliative care is not solely for end-of-life situations. It can be provided alongside curative treatments, aiming to improve the quality of life for patients facing serious illnesses at any stage.
The Centers for Medicare Services (CMS) further elaborates on palliative care:
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. Addresses the patient’s physical, mental, social, and spiritual well-being, is appropriate for patients in all disease stages, and accompanies the patient from diagnosis to cure. Uses life-prolonging medications. Uses a multi-disciplinary approach using highly trained professionals. Is usually offered where the patient first sought treatment.
CMS highlights the comprehensive nature of palliative care, addressing physical, mental, social, and spiritual needs throughout the illness journey, from diagnosis onward. Importantly, palliative care can include life-prolonging treatments.
In contrast, CMS defines hospice care with distinct characteristics:
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 treatments are no longer pursued. It prioritizes comfort and end-of-life preparation, typically excluding life-prolonging medications.
NIH defines comfort care as:
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 focused on relieving suffering and improving quality of life at the end of life, aligning closely with the goals of hospice care. It is a component within both palliative and hospice care, but the terms are not interchangeable with palliative care in broader medical contexts.
ICD-10-CM Coding for Palliative Care
For medical coding palliative care accurately, the ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) provides specific guidance. While “Comfort Care” and “Hospice” are not directly indexed, “Palliative care” leads to code Z51.5 Encounter for Palliative Care.
Within the ICD-10-CM tabular list, the Z51 category instructs to “Code also condition requiring care,” but no further instructions are present at the Z51.5 code level itself. This means when coding palliative care, coders should also include the underlying condition necessitating the palliative care, providing a complete picture of the patient’s medical situation.
Alt text: A medical coding professional carefully reviews the ICD-10-CM codebook, focusing on guidelines for palliative care coding.
The American Hospital Association (AHA) Coding Clinic Q3 2010 clarifies that “Comfort Care” and “End of life care” should also be coded using Z51.5, Encounter for Palliative Care. This guidance is crucial for coders to ensure consistent and accurate coding practices across healthcare facilities. While official updates to the ICD-10-CM tabular list to include “Comfort Care” and “End of life care” under Z51.5 could enhance clarity, current coding practice relies on AHA Coding Clinic guidance.
Several AHA Coding Clinics further discuss and refine palliative care coding, offering valuable insights for coders. These include:
- 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 essential for a comprehensive understanding of evolving coding guidelines and best practices for coding palliative care.
Notably, with the FY2022 coding updates (effective October 1, 2021), the CDC’s National Center for Health Statistics exempted code Z51.5 Encounter for Palliative Care from Present on Admission (POA) reporting. This exemption simplifies the coding process for palliative care encounters, recognizing that palliative care might be initiated during a hospital stay.
It’s vital to confirm that palliative care services have actually commenced during an encounter before assigning the Z51.5 code. Documentation should clearly indicate the initiation of palliative care. Hospitals should establish clear documentation protocols, ensuring palliative care staff and coding teams are aligned on documentation practices to support accurate code assignment.
Related Important Z Codes
Beyond Z51.5, other Z codes are relevant in the context of palliative care and end-of-life care documentation.
“Do Not Resuscitate” (DNR) orders are a critical aspect of patient wishes, particularly in palliative and end-of-life care. In ICD-10-CM, DNR is indexed under “DNR” leading to code Z66 Do Not Resuscitate. The tabular list includes “DNR status” as an inclusion term, further clarifying the code’s application.
Alt text: A compassionate doctor engages in a discussion about a Do Not Resuscitate (DNR) order with a patient and their family in a hospital setting.
Code Z66 is not only crucial for reflecting patient preferences but also impacts quality scoring algorithms and mortality metrics. Hospitals often utilize Z66 to exclude cases with DNR orders from mortality reviews, ensuring a more accurate analysis of quality of care.
Another valuable Z code is Z75.1 Person awaiting admission to adequate facility elsewhere. This code becomes relevant in situations where patients, often palliative care patients, experience extended hospital stays due to challenges in securing placement in post-acute care facilities like skilled nursing facilities or long-term care facilities.
Documenting Z75.1, when applicable, provides valuable data for mortality methodologies and algorithms. Reviewing case management and discharge planning documentation is key to identifying cases appropriate for Z75.1 assignment. Hospitals are encouraged to discuss the use of Z75.1 with clinical documentation integrity (CDI) and coding staff to ensure consistent application and data capture.
Currently, no official guidelines or AHA Coding Clinic specific guidance exists for Z75.1 coding. However, proactive reporting of Z75.1 can offer valuable insights into resource utilization and patient flow challenges. Analyzing data reports on Z75.1 and its impact on Length of Stay (LOS) can inform hospital operations and resource allocation.
The Importance of Accurate Coding for Palliative Care Data
Accurate coding palliative care, including the use of relevant Z codes, is vital for data integrity and reporting. CMS MedPAR data, which relies on principal and secondary diagnosis codes reported on claims, utilizes this coded information for various purposes.
Ensuring accurate coded data related to palliative care contributes to:
- Patient Care Insights: Understanding the prevalence and characteristics of patients receiving palliative care.
- Mortality and Quality Assessments: Refining mortality reviews and quality metrics by accounting for palliative care and DNR status.
- Healthcare Needs Forecasting: Providing data to inform future healthcare planning and resource allocation based on palliative care utilization and related factors like post-acute care placement challenges.
By prioritizing accurate coding palliative care and associated conditions and circumstances, healthcare facilities contribute to a robust and meaningful healthcare data ecosystem, ultimately benefiting patient care and healthcare system improvement.
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)
