# Palliative Care coding order for ICD-10 codes



## Judy Sylvester (Jan 10, 2018)

I am new to Palliative care coding for Inpatient care.  I have questions regarding both the sequencing of the ICD-10 code, Z51.5 and also the definition of "Code also condition requiring care".

To me, if a Palliative Care provider is called in to see a patient that has a terminal disease and the quality of life is now the issue, the code Z51.5 should be coded as primary and the terminal disease should follow.  Or should this be coded as the symptoms and reason for the inpatient stay, followed by the terminal disease and lastly the Palliative care Z code?  

For example:  Patient is inpatient and came in due to dyspnea that is associated with CHF and ESRD.  Palliative care was called to consult because cardiologist can not do anything else and the prognosis is not good.  Palliative care providers documents a thorough visit and discusses all options with the patient and family.  Would he code for the dyspnea, CHF, ESRD and then the palliative care code, in that order?  Or because of the instructions under A51, should he code the Palliative care code, followed by the CHF, ESRD?  If so, should he include the dyspnea?  

Any help would be greatly appreciated.


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## KZuppinger (Jan 11, 2018)

*ICD 10 Guidelines Code Also*

Hi 

The ICD-10 Guidelines at Z51 comes with a code also note. So in this case I would code the Z51.5 code first followed by the ESRD and the CHF. I would not code the dyspnea since it is a symptom of of CHF.


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## lrmccann (Jan 11, 2018)

so palliative care treats the signs and symptoms of a disease not the disease itself so I would code dyspnea. our providers code sign and symptoms first; example if we seen a patient for pain from lung cancer. they would first code g89.3 and then c34.90 and then z51.5. but we have been told by our hospital quality insurance coders that the order in which z51.5 is order does not matter our providers just continue to code last due to habit.


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## mitchellde (Jan 11, 2018)

Unless otherwise instructed by coding guidelines you code the reason for the encounter first listed.  If the palliative care provider is seeing the patient for pallative care purposes then z51.5 would be first listed.  You would not code the symptoms once a definitive diagnosis has been rendered that explains the symptoms.  Pain is a whole different issue.  There is an entire section on pain coding in the guidelines.  When the reason for the encounter is pain control/management then the G89 code for the type of pain does become the first listed code. Keep in mind these codes are not in the chapter for symptoms, they are in the chapter for disorders of the central nervous system, so this does not go contrary to the guideline of do not code the symptoms.
Also remember the providers are not coders and generally are unaware of coding rules regarding first-listed codes.


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## Quaker (Jan 24, 2018)

I agree with coding the Z code as initial followed by the reason for the consult, ie dyspnea, pain, etc.  I'm thinking there will most likely be another provider who reported the underlying reason (e.g. met ca dx) for the complaint (dyspnea).  If the palliative care provider also reports the Cancer dx, when another provider already billed for that dx, someone's claim is going to deny.

Has anyone been billing these types of services that can share their payer experiences?

RN, BSN, CPC, CPMA


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## charlottetweed (Feb 9, 2018)

KZuppinger said:


> Hi
> 
> The ICD-10 Guidelines at Z51 comes with a code also note. So in this case I would code the Z51.5 code first followed by the ESRD and the CHF. I would not code the dyspnea since it is a symptom of of CHF.



I agree.  I've been coding PC for a couple years.  With ICD 10 we have Z51.5 now.  I put it Primary and then other underlying diagnoses requiring PC.  Generally I don't use symptoms unless there is specific management for them. Ex:  Brain Mets with Headache related pain.  If the provider provided Rx for the related headache pain then I'd code that.    Since ICD10 and putting Z51.5 first I've had no issues with getting paid or anyone telling us they didn't because we "used" their diagnosis.  I think some of that symptom coding phobia is left over from ICD9 and a time when few carriers understand PC; or at least that has been my experience in this part of the Country.   Hope that helps


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