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Z66
ICD-10-CM
Do Not Resuscitate

Understanding Do Not Resuscitate (DNR) orders is crucial for healthcare professionals. This resource provides information on DNR documentation, medical coding for DNR, and clinical best practices related to No Code orders. Learn about the importance of accurate DNR forms and complying with DNR protocols in a healthcare setting. Explore the implications and ethical considerations of DNR and No Code designations for patients.

Also known as

DNR
No Code

Diagnosis Snapshot

Key Facts
  • Definition : A medical order instructing healthcare providers not to perform cardiopulmonary resuscitation (CPR) if breathing or heartbeat stops.
  • Clinical Signs : N/A - DNR is a medical order, not a diagnosis with specific clinical signs.
  • Common Settings : Hospitals, nursing homes, hospice care, and at home.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC Z66 Coding
Z51.5-

Do Not Resuscitate status

Identifies a patient with a DNR order.

I46.-

Cardiac arrest

Relates to sudden cessation of heart function, a situation where DNR may apply.

Z01.89

Encounter for other specified aftercare

Covers aftercare encounters where DNR orders might be discussed or reviewed.

Code-Specific Guidance

Decision Tree for

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Is DNR documented by a physician?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Do Not Resuscitate order. No CPR.
Allows Comfort Measures Only. Focus on comfort, not life extension.
Physician Orders for Life-Sustaining Treatment. Outlines patient wishes for end-of-life care.

Documentation Best Practices

Documentation Checklist
  • DNR documentation: patient's capacity confirmed.
  • DNR order: clearly stated in medical record.
  • DNR discussion documented: date, time, participants.
  • DNR form signed and witnessed, scanned to chart.
  • DNR code status communicated to care team.

Coding and Audit Risks

Common Risks
  • DNR Documentation

    Incomplete or missing DNR documentation can lead to coding errors and compliance issues.

  • DNR Order Validity

    Expired or improperly executed DNR orders pose risks for inappropriate resuscitation efforts.

  • Code Status Clarity

    Unclear or conflicting documentation of patient code status can create confusion during emergencies.

Mitigation Tips

Best Practices
  • Document DNR discussions clearly in the medical record.
  • Use standardized DNR forms for consistent documentation.
  • Ensure DNR orders are reviewed and updated regularly.
  • Educate patients and families on DNR implications.
  • Verify DNR code status during patient transitions of care.

Clinical Decision Support

Checklist
  • Confirm DNR documented in chart
  • Verify patient understanding of DNR
  • Check for signed DNR consent form
  • Ensure DNR order is current and updated
  • Communicate DNR status to care team

Reimbursement and Quality Metrics

Impact Summary
  • DNR coding impacts reimbursement through accurate reflection of care provided, impacting MS-DRG assignment.
  • Accurate DNR documentation and coding improve quality metrics related to end-of-life care and patient wishes.
  • DNR coding compliance ensures proper hospital reporting for regulatory requirements and performance benchmarks.
  • Precise DNR and No Code documentation minimizes claim denials related to medical necessity and level of service.

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Frequently Asked Questions

Common Questions and Answers

Q: How do I initiate a Do Not Resuscitate (DNR) order for a patient who has clearly expressed their wish for no resuscitation efforts?

A: Initiating a DNR order requires a clear understanding of the patient's wishes and medical condition. First, engage in a compassionate and detailed conversation with the patient to confirm their understanding of DNR implications, including the specific interventions that will be withheld (e.g., chest compressions, intubation, defibrillation). Document this conversation thoroughly in the patient's medical record, including their capacity to make decisions. If the patient lacks capacity, engage with their designated surrogate decision-maker or follow established legal protocols within your jurisdiction. Next, ensure a valid DNR order is entered into the patient's chart and clearly communicated to all members of the healthcare team. Consider implementing an easily identifiable system, such as a wristband or prominent chart marker, to alert all staff of the DNR order. Explore how standardized DNR order forms can enhance communication and minimize errors in your clinical setting. This approach reinforces patient autonomy and respects their end-of-life preferences while ensuring legal and ethical compliance. Finally, regularly reassess the DNR order, particularly if the patient's condition or wishes change. Learn more about navigating complex DNR discussions with patients and families.

Q: What are the ethical and legal implications of implementing a DNR (No Code) order in the face of family disagreement?

A: Navigating DNR orders when there is family disagreement can be ethically and legally challenging. Prioritize open and honest communication with the family, explaining the patient's wishes (if documented) and the medical rationale for considering a DNR. If the patient possesses decision-making capacity, their wishes supersede those of the family. However, if the patient lacks capacity, determine if a legally designated surrogate exists. If no designated surrogate is available, many jurisdictions have established hierarchies for surrogate decision-making, typically involving close family members. Emphasize shared decision-making and offer mediation or ethics consultations to facilitate communication and resolve conflicts. Document all discussions and decisions meticulously in the medical record. If consensus cannot be reached and family members contest the DNR decision, consider consulting with legal counsel to understand the specific legal requirements in your jurisdiction. Explore how institutional ethics committees can provide valuable guidance and support in such situations. Remember to prioritize patient-centered care while balancing the ethical and legal obligations of respecting family involvement.

Quick Tips

Practical Coding Tips
  • Document DNR explicitly in chart
  • Code DNR per facility policy
  • Use standardized DNR terminology
  • Check for POLST/MOLST forms
  • Consider underlying condition codes

Documentation Templates

Patient has expressed a desire for a Do Not Resuscitate (DNR) order, also known as a No Code order.  This discussion regarding end-of-life care and resuscitation status was conducted with the patient, who demonstrates capacity for medical decision-making.  The patient understands the implications of a DNR order, including withholding cardiopulmonary resuscitation (CPR), intubation, and defibrillation in the event of cardiac or respiratory arrest.  The rationale for the DNR order is consistent with the patient's overall goals of care and prognosis.  The medical risks and benefits of CPR were explained, and alternative comfort measures were discussed.  The patient's decision is documented in the medical record and a DNR order has been entered.  This information has been communicated to the patient's family and the entire healthcare team to ensure adherence to the patient's wishes.  Documentation of this DNR order will be reviewed periodically and updated as necessary, particularly with any changes in the patient's condition or treatment plan.  This DNR order is in accordance with hospital policy and ethical guidelines regarding end-of-life care. Billing codes and medical coding related to advance care planning will be applied as appropriate.