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Documentation that a patient has a substantial risk of death within 1 year (Pall Cr)

CPT4 code

Name of the Procedure:

Palliative Care Coordination (Pall Cr)


Palliative care coordination is a comprehensive approach focused on providing relief from the symptoms, pain, and stress of a serious illness for patients who have a substantial risk of death within one year. This care is tailored to improve quality of life for both the patient and their family.


Palliative care coordination addresses the significant medical, psychological, and social challenges faced by patients with serious illnesses. The primary goal is to enhance the patient's quality of life through symptom management, emotional support, and detailed care planning.


  • Advanced stages of serious illnesses such as cancer, heart failure, chronic obstructive pulmonary disease (COPD), and neurodegenerative diseases.
  • Patients experiencing substantial pain, severe fatigue, or complex psychological distress.
  • Individuals with a prognosis suggesting a high risk of death within one year.
  • Patients and families needing assistance with making care decisions and planning future medical treatment.


  • There may be discussions about patient and family preferences, values, and goals of care.
  • Review of current medications and treatments.
  • Coordination with the primary care physician and specialists.
  • No specific fasting or physical preparation required.

Procedure Description

  1. Initial Assessment: A comprehensive evaluation by a palliative care team, which may include doctors, nurses, and social workers.
  2. Care Planning: Development of a personalized care plan aiming to address the patient's physical, emotional, and spiritual needs.
  3. Symptom Management: Ongoing treatments for relief from pain, nausea, shortness of breath, and other distressing symptoms.
  4. Support Services: Provision of counseling, support groups, assistance with medical decision-making, and help navigating the healthcare system.
  5. Coordination: Regular coordination with the patient's other healthcare providers to ensure a unified approach.


Initial consultations typically last 1-2 hours, with follow-up appointments depending on the patient's needs and progression of the illness.


This procedure can be performed in various settings, including hospitals, outpatient clinics, in-home care setups, and specialized palliative care centers.


  • Palliative Care Physicians
  • Specialist Nurses
  • Social Workers
  • Psychologists or Counselors
  • Clinical Chaplains

Risks and Complications

  • Emotional and psychological challenges during discussions about end-of-life care.
  • Potential for disagreement among family members regarding care plans.
  • Minimal medical risks involved, given the non-invasive nature of the coordination.


  • Improved management of symptoms such as pain and fatigue.
  • Enhanced quality of life for the patient.
  • Better psychological and emotional support for both the patient and their family.
  • More informed and aligned medical decision-making.


  • Ongoing and tailored support with no defined recovery phase as it varies based on the patient's condition and progression.


  • Standard medical care without specialized palliative support, which may not address complex symptom management and psychosocial needs as effectively.
  • Hospice care for patients typically with a prognosis of six months or less to live.
  • Pros: Palliative care provides a more holistic approach, involving a team to support the patient's overall well-being.
  • Cons: Standard care might be less comprehensive in managing quality of life and long-term goals.

Patient Experience

  • Patients might initially feel overwhelmed by discussions about end-of-life planning, but it leads to greater peace of mind in the long run.
  • Symptom relief and emotional support help patients feel more comfortable and supported.
  • Pain and symptom management strategies tailored to improve daily living.
  • Comfort measures are continually adapted to the patient's evolving needs.

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