Home Health ICD-9/ICD-10 Alert

Question: We have a hospice patient who has inoperable cancer of the medulla oblongata of the brain. We are providing pain control and management of other symptoms. There is a do not resuscitate order (DNR) in place. How should we code for this patient?

New Hampshire Subscriber

Answer: Before you can code for this patient, you need to know the focus of care. Ordinarily you can choose between the pain management as the condition chiefly responsible for the patient’s admission or the management of symptoms of the cancer as the principal diagnosis. However, with hospice, pain management doesn’t qualify as a primary diagnosis, so the brain cancer should be placed as primary.

If management of all cancer-related symptoms including the pain is the focus of care, you would code for this patient as follows:

·         191.7 (Malignant neoplasm of brain stem);

·         338.3 (Neoplasm related pain [acute] [chronic]);

·         V66.7 (Encounter for palliative care); and

·         V49.86 (Do not resuscitate status).

In this scenario, your principal diagnosis is the brain cancer of the medulla oblongata, so you’ll list 191.7 first. Follow this with 338.3 to indicate neoplasm-related pain.

Next, you can list V66.7 to indicate that you’re providing palliative care for this patient. Remember, V66.7 is a secondary-only code so you can never report it as primary. This code also includes end-of-life care, hospice care, and terminal care.

Finally, list V49.86 to indicate that you have a physician’s order for “do not resuscitate.”

If this patient was not a hospice patient and your focus of care was instead the neoplasm-related pain, you would sequence the diagnoses differently:

·         338.3;

·         191.7;

·         V66.7; and

·         V49.86.

When pain management is the focus of care, the guidelines instruct coders to list the pain management code first (338.3 in this case). If this was true in a non-hospice patient’s case, you would follow the pain management code with 191.7 to indicate that the patient has a brain neoplasm.