We’re facing challenges with our billing team regarding the use of Z51.5 (Encounter for Palliative Care) as the principal diagnosis. Our physicians sometimes admit patients specifically for palliative or comfort care, but our pre-bill system flags these cases when Z51.5 is the primary diagnosis. We’re seeking clarity on the correct coding practices for these scenarios and wondering what others are doing.
Here are a couple of examples to illustrate the situation:
- A patient arrives in the Emergency Department with a hemorrhagic stroke. After discussing options, the family decides against aggressive interventions. The physician then writes an admission order specifically for Palliative Care/Comfort Care.
- An oncology patient, previously opting for home hospice, is admitted from home. The family becomes uncomfortable managing care at home and requests inpatient admission for comfort care until the patient’s expected imminent death.
According to Coding Clinic, 1st Quarter ICD-10 2017, pages 48-49, there is guidance on this topic:
Question: Can code Z51.5, be listed as principal diagnosis when the reason for the encounter is to receive palliative care?
Answer: Yes, assign code Z51.5 as principal diagnosis when palliative care is documented as the reason for the patient’s admission. Z51.5, encounter for palliative care, is used to classify admissions or encounters for comfort care, end-of-life care, hospice care, and terminal care for terminally ill patients. It may be used in any health care setting. Code Z51.5 can be used in multiple care settings where it may be the first-listed diagnosis, but it is typically not the principal diagnosis in the inpatient hospital setting. In many cases, it would be more appropriate as a secondary diagnosis, because it is not normally the reason for a hospital inpatient admission.
This Coding Clinic advice confirms that Z51.5 can be used as a principal diagnosis when the primary reason for admission is indeed palliative care. This applies across various healthcare settings. However, it also highlights a crucial point: in the inpatient hospital context, Z51.5 is typically not the principal diagnosis.
Understanding When Z51.5 is an Appropriate Principal Diagnosis
The key to correctly applying Z51.5 as a principal diagnosis lies in understanding the reason for the encounter. If the primary purpose of the admission or encounter is to provide palliative care, then Z51.5 is appropriately sequenced as the principal diagnosis. This is especially true in settings outside the inpatient hospital. Examples of such settings where Z51.5 as principal diagnosis is more common include:
- Outpatient clinics specializing in palliative care: Patients may be seen specifically for palliative care management, symptom control, and advance care planning.
- Home health and hospice settings: While hospice care itself is often indicated by other codes, encounters within a palliative home health service might legitimately have Z51.5 as the primary focus.
- Emergency Department visits: In certain situations, a patient might present to the ED primarily for palliative care needs, although this is less frequent for admission purposes.
Why Z51.5 is Often a Secondary Diagnosis in Inpatient Settings
The Coding Clinic clarifies that in the inpatient hospital setting, Z51.5 is “typically not the principal diagnosis” and “in many cases, it would be more appropriate as a secondary diagnosis.” This is because inpatient hospital admissions are generally driven by the underlying medical condition requiring acute care.
Let’s revisit the examples provided:
- Hemorrhagic Stroke: In the case of the patient with a hemorrhagic stroke, the reason for admission to the hospital is fundamentally the stroke itself. While the plan of care shifts to palliative or comfort care, the underlying diagnosis remains the primary driver for the inpatient admission. Therefore, the hemorrhagic stroke should be coded as the principal diagnosis, and Z51.5 would be a secondary diagnosis, reflecting the palliative care approach.
- Oncology Patient Transitioning from Home Hospice: Similarly, for the oncology patient, the underlying condition is cancer. The reason for inpatient admission in this scenario is the family’s inability to manage home hospice, necessitating a higher level of care in the hospital setting. While the focus is comfort care, the primary reason for needing inpatient hospital services, as opposed to continued home care or outpatient palliative care, is related to the complexities arising from the cancer and its progression. Again, the cancer diagnosis would likely be the principal diagnosis, with Z51.5 as secondary to denote the palliative care focus.
Practical Guidance
To navigate these situations effectively, consider the following:
- Clarify the Reason for Admission: Engage in discussions with physicians to ensure documentation clearly reflects the reason for admission. Is the patient being admitted primarily for palliative care management in a hospital setting, or is the admission driven by an underlying acute condition, with palliative care being the chosen direction of treatment?
- Context Matters: The healthcare setting is crucial. Z51.5 is more likely to be a principal diagnosis in outpatient palliative care clinics or home health palliative care. In acute inpatient settings, it’s often secondary.
- Underlying Condition as Principal Diagnosis: In most inpatient hospital admissions, even when palliative care is the focus of treatment, the underlying disease or condition that brought the patient to the hospital will be the more accurate principal diagnosis. Z51.5 then serves to further specify the type of care being provided.
- Review Payer Guidelines: While Coding Clinic provides official guidance, always be mindful of specific payer policies, as they may have additional or differing requirements.
Conclusion
While Coding Clinic confirms Z51.5 can be a principal diagnosis when palliative care is the documented reason for encounter, its use as a principal diagnosis in the inpatient hospital setting is generally less common. Accurate coding requires careful consideration of the primary reason for admission. In most inpatient scenarios, the underlying medical condition necessitating hospitalization will be the principal diagnosis, with Z51.5 appropriately used as a secondary code to reflect the palliative care being provided. Consistent communication between coding, CDI, billing teams, and physicians is essential to ensure accurate and compliant coding practices for palliative care encounters.
