palliative care

edited April 2016 in Clinical & Coding
This is more of a core measure question, but hopefully someone knows or has resources. We were told that a patient that has been made 'palliative care' will not be excluded from core measure data unless the order was on admit or up to the first day. After that, they cannot be excluded. Anyone?

Christine Reed, RN, BSN
Clinical Documentation Specialist
CDIP Team Leader
Elkhart General Hospital
Phone: (574) 389-5665
Pager: (888) 301-9402
Please note my new e-mail address:
Email: careed@beaconhealthsystem.org

Comments

  • edited April 2016
    Christine,
    Please see attached information:


    News: Important change impacts all CDI programs that review mortality charts

    CDI specialists that incorporate quality measures review in their duties take note: The Joint Commission on Dec. 16 updated its Specifications Manual for National Hospital Inpatient Quality Measures. Effective for discharges July 1, 2012, patients documented as receiving "Palliative Care" and "Palliative Measures" will not be excluded from quality improvement measures.
    Release Notes version 4.1 of the Specifications Manual states:

    "Since palliative care is increasingly being offered as a care program provided with curative treatment, patients should not be excluded from quality improvement measures because they enter a palliative care program."

    Patients who receive palliative care are currently excluded from certain quality measures. CDI specialists should query for documentation of the term "comfort care," when appropriate, to ensure that these types of patients are properly excluded.

    Note that comfort care "includes attention to the psychological and spiritual needs of the patient and support for the dying patient and the patient's family. Comfort Measures Only are not equivalent to the following: Do Not Resuscitate (DNR), living will, no code, no heroic measure," according to the Specifications Manual.

    Visit the Joint Commission web site to download the latest Specifications Manual.


    Editor's Note: This information was provided courtesy of Cheryl Ericson, MS, RN, manager of Clinical Documentation Integrity and core measures abstraction for the Medical University of South Carolina and a member of the ACDIS Advisory Board.
    Back to top


    I hope this helps.
    Lisa

    Lisa Romanello, RN,BSN,FNS,CCDS
    CDI Specialist
    CJW Medical Center
    Chippenham Campus
    804-228-6527

  • edited April 2016
    Thank you! That is exactly what I was looking for.

    Christine Reed, RN, BSN

  • Our latest Healthgrades result showed we scored poorly on using "palliative care" coding in regard to heart failure patients. I am educating physicians to use whenever the decision is made to stop aggressively treating the HF and the patient is deciding to go home on "comfort care". I just get it on the discharge summary when the plan of care is to go home on hospice. I am proposing that nursing do a PIP bc we have no formal program for these patients, and it seems like a great quality initiative. I'd love to know more about your program. Agreed that the patient can still be treated in a Palliative Care Program, but we don't have anything like that in place.

    Best Regards,

    Cari Merlina RN, BSN
    Clinical Documentation Improvement Specialist
    Revenue Cycle
    Yampa Valley Medical Center
    p.970.871.2425
    f.970.875.2796
    Cari.merlina@yvmc.org
    [yvmc]







  • Thanks Dr. G. I am seeing some inconsistencies in how this is being coded.



    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404



  • Our Healthgrades contact sent me information (attached) that states" ...increasing recognition and acceptance of the importance of high-quality palliative care as an integral component of comprehensive critical care for ALL ICU patients, REGARDLESS OF PROGNOSIS,...."
    I think it's a great initiative to include clear and compassionate communications by clinicians.
    I have proposed nursing do a PIP on this.


    Best Regards,

    Cari Merlina RN, BSN
    Clinical Documentation Improvement Specialist
    Revenue Cycle
    Yampa Valley Medical Center
    p.970.871.2425
    f.970.875.2796
    Cari.merlina@yvmc.org









  • I haven't had the time to research, but would love to see coding guidelines on Palliative Care coding, if any.

    Best Regards,

    Cari Merlina RN, BSN
    Clinical Documentation Improvement Specialist
    Revenue Cycle
    Yampa Valley Medical Center
    p.970.871.2425
    f.970.875.2796
    Cari.merlina@yvmc.org









  • I am seeing some coders applying the code whenever palliative care is provided (which because of our robust program is practically all our ICU patients) and then others only coding it if it was on admission, not if they were transitioned later. There are several coding clinics that address these issues:


    Encounter for palliative care

    Coding Clinic, Fourth Quarter 1996 Page: 47 to 48 Effective with discharges: October 1, 1996

    Related Information

    PALLIATIVE CARE

    Code V66.7, Encounter for palliative care, has been created effective October 1, 1996 to classify encounters for end-of-life care, hospice care and terminal care. Code V66.7 may not be used as the principal diagnosis. Sequence first the underlying disease, such as carcinoma, AIDS, etc. Code V66.7 may be assigned as an additional code to identify patients who receive palliative care in any health care setting, including a hospital.

    Palliative care is an alternative to aggressive treatment for patients who are in the terminal phase of their illness. Palliative care is focused towards management of pain and symptoms, and is often more appropriate than aggressive hospital treatment for patients dying of incurable diseases. The care provided is dependent on the terminal illness. Currently, between 20-30% of health care expenditures in the United States are devoted to treating persons in their last year of life. More than half of the costs of care during the last year of life are spent in the last 90 days of life.

    Question:



    A patient is admitted with end-stage lung cancer for palliative care only. How should this be coded?


    Answer:


    Assign code 162.9, Malignant neoplasm of bronchus and lung, unspecified, and code V66.7, Encounter for palliative care.


    Clarification - palliative care

    Coding Clinic, First Quarter 1998 Page: 11 to 12 Effective with discharges: January 15, 1998

    Related Information




    Clarification, Palliative Care



    A new code for palliative care, V66.7, became effective October 1, 1996. A brief explanation of how it should be used was published in Coding Clinic, Fourth Quarter 1996. A further explanation is now being provided to clarify the proper use of the code.



    Code V66.7 can be used for any terminally ill patient receiving palliative care. It is always a secondary code. The terminal condition should be the principal diagnosis. It may be used when a patient is brought in for aggressive treatment for a terminal condition and during the encounter it is determined that further aggressive treatment is no longer appropriate and palliative care is initiated.



    The physician documentation in the medical record must substantiate that palliative care is being given. Terms such as comfort care, end-of-life care, and hospice care are all synonymous with palliative care. These, or similar terms, need to be written in the record to support the use of code V66.7. The physician should be queried if the treatment record seems to indicate that palliative care is being given but the documentation is unclear. The care provided must be aimed only at relieving pain and discomfort for the palliative care code to be applicable.


    Palliative care

    Coding Clinic, Third Quarter 2008 Page: 13 to 14 Effective with discharges: September 19, 2008

    Related Information




    Question:



    An elderly patient with metastatic lung carcinoma is admitted with fever and chills and is diagnosed with pneumonia and urinary tract infection. The principal diagnosis is pneumonia. During the hospitalization, the patient develops severe sepsis and respiratory failure requiring a ventilator. On the day before the patient expires, she is extubated and taken off of Levophed. On the day she expired, the physician documented, "extubated yesterday with goals of comfort/ palliative care." In addition, the physician's plan states, "Continue palliative approach to respiratory failure--increase Morphine to limit work of breathing, stop intensive monitoring, consult palliative care service, continue scopolamine." The patient expired an hour after this note was written. Is it appropriate to assign code V66.7, Encounter for palliative care, as a secondary diagnosis in this situation?



    Answer:



    Yes, it would be appropriate to assign code V66.7, Encounter for palliative care, as a secondary diagnosis in this case. This code may be reported for any terminally ill patient who receives palliative care, regardless as to when the decision is made. There is no time limit or minimum for the use of this code assignment. As stated in Coding Clinic, First Quarter 1998, pages 11-12, "Code V66.7 can be used for any terminally ill patient receiving palliative care. It is always a secondary code. The terminal condition should be the principal diagnosis. It may be used when a patient is brought in for aggressive treatment for a terminal condition and during the encounter it is determined that further aggressive treatment is no longer appropriate and palliative care is initiated."


    Comfort care

    Coding Clinic, Third Quarter 2010 Pages: 18-19 Effective with discharges: October 1, 2010

    Related Information


    Question:



    The patient, an 88-year-old male, was admitted to the intensive care unit (ICU) following a massive intracerebral hemorrhage. Because of patient age, the size of the hemorrhage, and poor prognosis, a conference was held with the family and they agreed to discontinue life support and declined placement of a feeding tube. The provider documented comfort care and pain control. What clinical protocol is required in order to assign code V66.7, Encounter for palliative care? Is it appropriate to assign code V66.7 as a secondary diagnosis?



    Answer:



    Yes, assign code V66.7, Encounter for palliative care, as an additional diagnosis. Code V66.7 is for use to describe comfort care, palliative care and/or end of life care for terminally ill patients. If, however, the documentation is not clear regarding palliative care versus nonpalliative, query the provider for clarification. It is beyond the scope of the Editorial Advisory Board for Coding Clinic to provide clinical protocol for palliative care.




    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404



  • Thank you so much. It still begs the question, is the code only to be used for end of life care, as described in the first paragraph that you cite? I love that your facility has a "robust" Palliative Care Team! I'd love to know more once we get a plan in place for ours. Acc to Dr. Gold, it should only be used when basically just providing fluids and pain meds. I'm sure the ICU patients at your facility are receiving more treatment than that, but still receiving "palliative care". I have no idea why our Healthgrades folks are focusing on the diagnosis of Heart Failure and what % of the time we included the code for "palliative care". We got dinged some stars for our crappy scores. Anyone else with thoughts?
    cari


  • From my read of the coding clinics, it should only be sued when we are focusing solely on comfort/hospice/end-of-life care. Our palliative care team often manages pain on complex patients pursuing aggressive treatment as well. They also are consulted for code determinations and planning of end of life care in non-terminal patients. I don’t think the code should be applied in these cases.
    I love our palliative care team! They are invaluable and I recommend them for everyone facing a terminal/life altering dx even when death is not eminent. But it seems to me that the code is meant to capture 'comfort care' not everyone receiving palliative care (including those also receiving aggressive care). Seems like a bit of a disconnect between the clinical and coding language...

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404



  • Agree w/ Katy



    [cid:image001.png@01D1792A.E8093580]







    Paul Evans, RHIA, CCS, CCS-P, CCDS



    Manager, Regional Clinical Documentation

    Sutter West Bay

    633 Folsom St., 7th Floor, Office 7-044

    San Francisco, CA 94107

    Cell: 415.412.9421







    evanspx@sutterhealth.org










  • UpToDate sums it up quite nicely:

    Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering as well as supporting the best possible quality of life for patients and their families facing serious illness. While all care that is delivered by hospice can be considered palliative care, not all palliative care delivered is in hospice. Palliative care can be appropriately offered to patients at any time along the trajectory of any type of serious life-threatening illness, even concurrent with restorative, life-prolonging therapies.

    Clearly the 'encounter for Palliative care' code is meant to capture comfort or hospice care which is a portion of the patients that receive palliative care.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404



  • Agreed on the "disconnect"!:)

    Best Regards,

    Cari Merlina RN, BSN
    Clinical Documentation Improvement Specialist
    Revenue Cycle
    Yampa Valley Medical Center
    p.970.871.2425
    f.970.875.2796
    Cari.merlina@yvmc.org








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