From the Guidelines
There is no specific ICD-10 code that directly indicates a prognosis of less than six months to live. Instead, the underlying terminal condition causing the limited life expectancy would be coded using the appropriate ICD-10 code for that disease or condition. For example, if the patient has terminal lung cancer, the specific code for that type of cancer would be used. Additionally, code Z51.5 "Palliative care" may be used as a supplementary code to indicate that the patient is receiving end-of-life care 1. When documenting terminal illness for hospice eligibility, healthcare providers typically use the specific disease codes along with documentation that supports the terminal prognosis, including declining functional status, weight loss, or other clinical indicators. The determination of a six-month prognosis is a clinical judgment made by physicians based on the patient's condition and disease trajectory rather than something directly represented by a single ICD-10 code. Some studies suggest that the criteria for hospice eligibility do not accurately predict death within 6 months 1, and a validated predictive model is needed to estimate the likelihood of death within 6 months for patients with certain conditions, such as COPD. However, the BODE index provides prognostic information over periods of time from 12 to 52 months, but it has not been validated for determining a risk of mortality greater than 50% at a 6-month time period needed to qualify for hospice care 1. In general, the use of ICD-10 codes for palliative care and hospice eligibility is guided by clinical judgment and documentation of the patient's terminal condition, rather than a single code that indicates a prognosis of less than six months to live. More recent studies, such as the one published in 2016, provide guidance on palliative care interventions based on estimated life expectancy, but do not address the specific issue of ICD-10 coding for prognosis 1. Therefore, the most appropriate approach is to use the specific disease codes and supplementary codes, such as Z51.5, to indicate palliative care, and to document the terminal prognosis based on clinical judgment and supporting evidence.
From the Research
ICD-10 Code for Less Than Six Months to Live
- The ICD-10 code for a patient with a prognosis of less than six months to live is not explicitly stated in the provided studies 2, 3, 4, 5, 6.
- However, study 2 mentions that identifying the seriously ill population using currently available data requires using ICD-10 to define severe medical conditions (SMCs), which may include patients with a prognosis of less than six months to live.
- Study 3 discusses the development of ICD-10 coding algorithms to define Charlson and Elixhauser comorbidities, but does not provide a specific code for a prognosis of less than six months to live.
- Studies 4, 5, 6 focus on the use of ICD-10 codes for documenting medical diagnoses, social needs, and emergency department visits, but do not provide a specific code for a prognosis of less than six months to live.
Relevant ICD-10 Codes
- Z51.5: Encounter for palliative care 5, 6
- Z51.89: Other specified aftercare 5, 6
- Z65: Problems related to other psychosocial circumstances 6
- Note: These codes may be relevant to patients with a prognosis of less than six months to live, but are not explicitly stated as such in the provided studies.
Limitations
- The provided studies do not explicitly state the ICD-10 code for a patient with a prognosis of less than six months to live.
- Further research is needed to determine the specific ICD-10 code for this condition.