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Ask the Expert

This month’s selection:

Inpatient question: Does the physician have to document terminology such as “end-of-life care, comfort measures” to code palliative care? Or can palliative care be added as a secondary code if documented by other staff, a registered nurse, Social Services, or a case manager and not by a physician? We don’t want to unnecessarily query the physician.

If a physician recommends palliative care or hospice care and these options are refused by the family or patient, can you still code palliative care because it was recommended?

An outside consultant told us we should be coding this type of conversation that results in a refusal, by a patient or family, with palliative care Z secondary code. Can you add a secondary palliative care code if it is recommended but refused?

An RHIA, CCS, in Pennsylvania



I am unable to find any authoritative references indicating that documentation from someone other than a privileged provider (ie, physician or nonphysician provider [NPP]) can be used to support palliative care. Coding Clinic does provide info on things we can take from other staff (ie, body mass index, external causes of injury, stages of pressure ulcers). I would recommend asking someone from a clinical standpoint: Is it appropriate for a registered nurse, Social Services, or case manager to order palliative care? I consulted with a nurse with an active Florida license. She confirmed that these types of orders cannot originate from sources other than the privileged provider (ie, physician or NPP).

Coding should be performed based on the documentation that the patient is receiving comfort care/palliative care. If the patient is not receiving those services because they were refused, then palliative care is not being provided and the definition of the code “Encounter for palliative care” is not met.

I agree with the consultant regarding the need to capture refusal of palliative care. I would recommend using a code from subcategory Z53.2x to describe that treatment was recommended but not carried out.

— Catrena L. Smith, CCS, CCS-P, CPCO, CPC, CIC, CPC-I, CRC, CHTS-PW, is an audit and education manager at KIWI-TEK.

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