Patient presents for palliative care consultation.  Primary diagnoses include advanced [Specify primary diagnosis e.g., metastatic lung cancer, congestive heart failure, end-stage renal disease].  Patient is experiencing [Specify symptoms e.g., pain, dyspnea, nausea, fatigue, anxiety, depression].  Performance status is [Specify performance status e.g., ECOG, Karnofsky].  Goals of care discussion was conducted with the patient and [Specify who was present e.g., family, healthcare proxy].  Focus is on symptom management, quality of life, and psychosocial support.  Patient's understanding of prognosis and treatment options was assessed.  Plan includes [Specify interventions e.g., pain management with opioids, referral to hospice, spiritual counseling, nutritional support, advance care planning].  Discussed potential complications such as opioid-induced constipation, nausea, and respiratory depression.  Patient education provided regarding medication management, side effects, and when to seek further medical attention.  Follow-up scheduled in [Specify time frame e.g., one week, two weeks].  ICD-10 code Z51.89 (Encounter for other specified aftercare) is considered for billing along with appropriate codes for the underlying condition and symptom management.  CPT codes for palliative care consultation (99201-99215) will be selected based on the complexity of the visit.  Documentation will reflect time spent in counseling and coordination of care.