Z Codes: Understanding Palliative Care and Related Z Codes

Palliative care is often considered to be hospice and comfort care.

Palliative care is sometimes used interchangeably with “comfort care” and then again sometimes with “hospice care.”  But these terms do have slightly different meanings and sometimes the meaning varies depending on who is stating it.

The National Institute on Aging which is part of the National Institute of Health (NIH) states the following regarding palliative care:

Palliative care is 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.

According to the Centers for Medicare Services (CMS), palliative care is defined as following:

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.

While CMS describes this for hospice care:

• 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.

According to NIH, the definition of comfort care is the following:

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.

In the ICD-10-CM the term/word “Comfort Care” and “Hospice” are not in the alphabetic index, while “Palliative care” is, with direction to see code Z51.5 Encounter for Palliative Care in the tabular.

In the tabular you will find there an instruction at the Z51 category level to “Code also condition requiring care,” but there are no other inclusion terminology or other instructional wording at Z51.5 code level.

However, the American Hospital Association (AHA) Coding Clinic Q3 2010 does state that “Comfort Care” as well as “End of life care” would be coded to Encounter for Palliative Care. [Adding “Comfort Care” and “End of life care” to the tabular might be something for a future addition to ICD-10-CM.]  There are however several AHA Coding Clinics that mention or discuss Palliative Care coding that should be reviewed thoroughly:

• 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

With the FY2022 coding updates (10/1/2021), the code Z51.5 Encounter for Palliative Care was added to the Exempt from POA Reporting List by the Centers for Disease Control and Prevention (CDC) its National Center for Health Statistics.

Sometimes the hospital encounter documentation indicates that an order will be placed for the palliative care, but the palliative care doesn’t actually get started during that stay for some reason, so be sure the palliative care actually starts in the encounter you are assigning the Z51.5 code.

You might want to discuss this with your palliative care staff so it is clear what the documentation will look like and where in the health record it will routinely occur.

A standard practice for hospitals and most medical facilities is to ask about the patient wishes to be resuscitated should they go into cardiac or respiratory arrest during the hospital stay or encounter. There may be a form that the patient completed, referred to as “DNR” or “Do Not Resuscitate.”  Documentation of this is the medical record and tells the physician and medical professionals caring for the patient that they should not initiate cardiopulmonary resuscitation (CPR) if the patient stops breathing or their heart stops.

Another important Z code to capture for this is “Do Not Resuscitate” or “DNR.”  In ICD-10-CM, Do Not Resuscitate is listed in the alphabetic index under “DNR” for code Z66. In the tabular Z66 Do Not Resuscitate, has the inclusion terminology of “DNR status.”

Often there are quality scoring algorithms or metrics that this Z66 code can impact. In fact, sometimes acute hospital death encounters being studied for mortality and quality of care will check for the Z66 code and exclude those hospital death cases from review. Certainly, this is important when reviewing mortality data on hospitalizations.

As we know from reading the inpatient medical records and talking with hospital colleagues, there is a shortage on post-acute care placement facility beds. We have seen the hospital length of stay (LOS) be extended due to difficulty with post-acute placement to a skilled nursing facility, long-term care facility, rehabilitation facility, etc.

The other Z code that can be of value is Z75.1 Person awaiting admission to adequate facility elsewhere. Some mortality methodologies and algorithms look for this code. When reviewing the medical record for coding assignment look at the case management and discharge planning documentation.

Discuss with your clinical documentation integrity (CDI) and coding staff so everyone is on the same page regarding code Z75.1 as a secondary (additional) ICD-10-CM code.

Currently, there are no official guidelines or AHA Coding Clinic specific guidance on the coding and reporting of Z75.1 code. Be proactive in coding and reporting this specific situation and run a data report on Z75.1 for the past year and see how often this has been reported at your facility. Then check the MS-DRG LOS on those cases with the Z75.1 code.

Also, look at your average length of stay (LOS) for MS-DRGs and those with a higher LOS than the GMLOS without the Z75.1 code might need a quick review. [Thank you to a CDI colleague who mentioned the use of this Z code to me recently.]

CMS MedPAR (Medicare Provider Analysis and Review) data uses the hospital inpatient principal diagnosis code and 24 additional or secondary diagnosis codes that are on the claim (UB04).

Ensuring that your coded data gets into the CMS database and others (i.e., state) is vital to accurate reporting as they provide details on patient car, mortality, quality as well as insight into future healthcare needs.

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)