AHA Coding Clinic® for ICD-9 - 2008 Issue 3; Ask the Editor
Palliative Care
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? ...
Subscribe or sign in to view the full article.
Article Overview
This article discusses a clinical documentation scenario involving terminal illness, respiratory failure, comfort-focused treatment, and palliative care language. It is intended for coders, CDI professionals, and reimbursement staff who need to understand how the case is interpreted for coding purposes and what documentation elements are relevant.
Why This Topic Matters
End-of-life and palliative care documentation can affect diagnosis selection, sequencing, and how the record is interpreted for coding review. Understanding the scenario helps coding professionals evaluate whether the chart supports the intended clinical picture without overcoding.
What You Will Learn
- How palliative care language appears in end-of-life documentation
- How a terminal hospitalization scenario may be evaluated for coding relevance
- What types of documentation elements are considered in palliative care-related coding questions
- How palliative care discussions intersect with serious illness, respiratory failure, and comfort-focused treatment
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement specialists
- Health information management professionals
- Reimbursement staff
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com