The CMS Hospice Manual states Z codes can't be reported as PDx.
Non-reportable Principal Diagnosis Codes to be returned to the provider for correction:
• Hospices may not report ICD-9CM v-codes and ICD-10-CM z-codes as the principal diagnosis on hospice claims.
• Hospices may not report debility, failure to thrive, or dementia codes classified as unspecified as principal hospice diagnoses on the hospice claim.
• Hospices may not report diagnosis codes that cannot be used as the principal diagnosis according to ICD-9-CM or ICD-10-CM Coding Guidelines or require further compliance with various ICD-9-CM or ICD-10-CM coding conventions, such as those that have principal diagnosis code sequencing guidelines.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3930CP.pdf------------------------------
Chrystel Barron, RHIA, CCS, CCS-P, CHTS-TR, CICA
Coding Education Instructor
Cleveland Clinic Health System
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Original Message:
Sent: 12-05-2018 18:16
From: Margaret Foley
Subject: Palliative Care Pdx in inpatient setting
Hi Ayana
Since the removal of code Z51.5 Encounter for Palliative Care from the MCE list of Unacceptable Diagnoses in October 2017, I've seen some acute care scenarios for which I would assign use of Z51.5 as the principal diagnosis. For example,
Patient with metastatic breast cancer is receiving home hospice care services. Oncology team is now admitting patient from home because the family is uncomfortable dealing with the patient's worsening pain, dyspnea and upper extremity edema. Admission order for acute care inpatient unit written for comfort care only for hospice patient with established DNR/DNI order. (I do realize that this scenario may have some concerns for medical necessity for an acute level of care.)
Although Z51.5 Encounter for Palliative Care is not commonly assigned as the principal diagnosis in the acute care setting, the 1st Quarter 2017 Coding Clinic, pp. 48-49, instructs to sequence Z51.5 as the principal diagnosis in some circumstances. Specifically, it states "Z51.5, Encounter for palliative care, is typically not assigned as the principal diagnosis in an acute care hospital setting because it is not normally a reason for admission in an acute care level of care. However, if the reason for a hospitalization is palliative care, code Z51.5 may be sequenced first.
For your first case, I would assign the code for the clinical condition (not the Z51.5) as the principal diagnosis.
Example 2, is less clear because the order for comfort care was not written until day two of the stay.
I am very interested in hearing when/if others are using Z51.5 Encounter for palliative care as a principal diagnosis for acute care inpatient admissions.
thanks
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[Maggie] [Foley]
[Associate Professor]
[Temple University]
Original Message:
Sent: 12-04-2018 11:34
From: Ayana Culley
Subject: Palliative Care Pdx in inpatient setting
How are acute care hospitals handling an admission for palliative care? Keeping in mind the Pdx is the chief reason for admission, after study and palliative care is no longer an unacceptable Pdx diagnosis.
Example 1, pt is brought to the ED- Diagnosed with Acute on Chronic CHF/Respiratory failure, pt intubated, however in the ED patient's family decides they would like palliative care and would like to withdraw intubation. Pt is admitted to ICU for "terminal extubation and palliative care".
Example 2 is the patient is admitted to the ED, diagnostic work-up of xrays, Ct-scan etc, diagnosed with advanced metastatic disease in the ED, the family is called and requests no further work-up and states they want palliative care via phone. The patient is admitted to inpatient care and IV fluids and meds are continued until the family arrives to sign the necessary paperwork. The following day orders are written for comfort care only after discussion with family.
Both of these situations have created intense debates about what the principal diagnosis should be. How are you all handling situations like this?
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Ayana Culley BSN,RN,RHIT,CCS, CHPN
AHIMA Approved ICD-10 CM/PCS Trainer
Vice President
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