Coding, Classification & Reimbursement

Palliative Care Pdx in inpatient setting

Carol L. Nickels, Health Information Administration,RHIA,CCS9 days ago

  • 1.  Palliative Care Pdx in inpatient setting

    Posted 11 days ago
    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
    ------------------------------


  • 2.  RE: Palliative Care Pdx in inpatient setting

    Posted 11 days ago
    ​Following

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    Jennifer Phillips, RHIT, CPC, CRC, CEMC, CGSC
    Auditor/Educator
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  • 3.  RE: Palliative Care Pdx in inpatient setting

    Posted 11 days ago
    Following

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    Michelle
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  • 4.  RE: Palliative Care Pdx in inpatient setting

    Posted 9 days ago
    I also would like some definite rules on when to use Palliative Care as Pdx in the acute setting.  In the 2nd example, I would not use Palliative Care as Pdx because, if I am reading the examples correctly,  the order for palliative care did not happen until the next day.  The first example is a little more confusing.  The reason after study:  Is this the CHF/breathing problem or palliative care?  If the patient did not have the CHF/breathing problem, there would not be the encounter for palliative care.  So which is Pdx?  And final, I also assume the "power of attorney" is being followed.  Any other thoughts out there?  Thanks everyone.

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    Nelda Laskey RHIT
    Coder/RAC Coordinator
    Kearny County Hospital
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  • 5.  RE: Palliative Care Pdx in inpatient setting

    Posted 8 days ago
    Yes, the second scenario the actual order was written the following day although it was discussed and the presumed plan was palliative care. Thanks for the feedback.

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    Ayana Culley BSN,RN,RHIT,CCS, CHPN
    AHIMA Approved ICD-10 CM/PCS Trainer
    Vice President
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  • 6.  RE: Palliative Care Pdx in inpatient setting

    Posted 8 days ago
    HI Nelda, That's a good point. It is all so gray.

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    Ayana Culley BSN,RN,RHIT,CCS, CHPN
    AHIMA Approved ICD-10 CM/PCS Trainer
    Vice President
    ------------------------------



  • 7.  RE: Palliative Care Pdx in inpatient setting

    Posted 10 days ago

    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



    ------------------------------
    [Maggie] [Foley]
    [Associate Professor]
    [Temple University]
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  • 8.  RE: Palliative Care Pdx in inpatient setting

    Posted 8 days ago
    Thanks, Maggie for your input.

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    Ayana Culley BSN,RN,RHIT,CCS, CHPN
    AHIMA Approved ICD-10 CM/PCS Trainer
    Vice President
    ------------------------------



  • 9.  RE: Palliative Care Pdx in inpatient setting

    Posted 6 days ago
    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

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    Chrystel Barron, RHIA, CCS, CCS-P, CHTS-TR, CICA
    Coding Education Instructor
    Cleveland Clinic Health System
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  • 10.  RE: Palliative Care Pdx in inpatient setting

    Posted 5 days ago
    Hi Chrystel,
    My understanding is that this pertains to hospice units. My question refers to Acute Care hospital admissions. Are you familiar with how that scenario would be handled?
    Thanks!

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    Ayana Culley BSN,RN,RHIT,CCS, CHPN
    AHIMA Approved ICD-10 CM/PCS Trainer
    Vice President
    ------------------------------



  • 11.  RE: Palliative Care Pdx in inpatient setting

    Posted 9 days ago

    I work in a LTCH and when the patient is a true LTCH patient, I pull the clinical condition to the PDX with the palliative code as a secondary.  If the patient is placed into hospice and is here solely for palliative care (typically because the family wants them to stay here), we discharge the patient from LTCH and readmit as a hospice patient with the Z code as PDX.  We bill hospice, not Medicare, for this stay.

    Gail



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    Gail Conklin, CCS
    HIM Manager, LTCH
    Carrus Specialty Hospital
    glawrence@carrushospital.comConklin
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  • 12.  RE: Palliative Care Pdx in inpatient setting

    Posted 9 days ago
    Per Coding Clinic guidance, Z51.5 is the appropriate PDX for inpatient accounts when the patient is admitted to a Hospice Program or Hospice (GIP) unit of an acute care hospital, regardless of the MCE edit.

    CC Palliative Care





















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    Carol Nickels, RHIA, CCS
    Coding and Documentation Review Consultant
    Kaiser Permanente - Regional Offices (Oakland, CA)
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  • 13.  RE: Palliative Care Pdx in inpatient setting

    Posted 9 days ago
    Why can you not  use Z51.5 as the principal diagnosis?

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    Rivona Wasserman
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  • 14.  RE: Palliative Care Pdx in inpatient setting

    Posted 8 days ago
    I think is more of a historical practice. Since it was an unacceptable pdx, no one used it and instead coded the underlying condition. I believe the waters became muddy when the coding clinic was published in the first quarter 2017 but the Z51.5 code remained on the unacceptable list until Oct 1, 2017. To further increase confusion, the first set of codebooks still listed it as an unacceptable diagnosis. This led to a lot of confusion and needed education. This historical view has led to many not even considering the Z51.5 as an option.

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    Ayana Culley BSN,RN,RHIT,CCS, CHPN
    AHIMA Approved ICD-10 CM/PCS Trainer
    Vice President
    ------------------------------



  • 15.  RE: Palliative Care Pdx in inpatient setting

    Posted 9 days ago

    What is the patient is just being followed by Palliative Care during an acute stay? Palliative Care addresses quality of life and is not necessarily for end of life/hospice care.

     



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    Terese Clark, RHIA, CCS
    Director Corporate Coding
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  • 16.  RE: Palliative Care Pdx in inpatient setting

    Posted 9 days ago

    Make that what if the patient is being followed by palliative care during an acute stay.

     

    Terry Clark, RHIA, CCS

    Director, Corporate Coding NTX

    Baylor, Scott & White

    (ph)817-637-6544

    terry.clark@bswhealth.org

     

    I commit to leading the HIM corporate coding team so that we will provide consistent and accurate coding and billing information.

     


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  • 17.  RE: Palliative Care Pdx in inpatient setting

    Posted 8 days ago
    If the patient was just being followed by palliative care during the stay but was admitted for an acute condition I would code the acute condition as the primary and the palliative as a secondary.

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    Ayana Culley BSN,RN,RHIT,CCS, CHPN
    AHIMA Approved ICD-10 CM/PCS Trainer
    Vice President
    ------------------------------



  • 18.  RE: Palliative Care Pdx in inpatient setting

    Posted 5 days ago

    I audit services on the pro-fee side for Palliative services.  I tell the Palliative providers to use the Z51.5 Encounter for Palliative care as their primary since this is the reason they are being called in.  According to CPT rules, the first diagnosis reported should be the primary reason for the encounter.  They should use the condition that initiated the Palliative care as secondary.  Using the Z51.5 as primary differentiates their services from that of the Cardiologist, Pulmonologist, etc.


    -Jennifer Phillips, RHIT, CPC, CRC, CEMC, CGSC

    Auditor/Educator II

    Corporate Compliance and Coding Support

    704-512-5917 fax: 704-393-1026


    Atrium Health

    Carolinas HealthCare System is Atrium Health

     4425 Golf Acres Dr. Charlotte, NC  28208



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