ICD-9 Medical Coding: Navigate Pain Code Compliance Traps


Let us look at pain and some of the specific medical coding guidelines surrounding pain. There is no formal timeframe that creates the difference between acute and chronic. On the average, acute pain typically last for less than three to six months following that tissue damage. Typically, it's associated with maybe a surgical insertion and accident or injury. Typically that pain tapers off or stops on its own after that heal.

In contrast, chronic pain is ongoing. Now, that six months timeframe is not a definitive item. We can have chronic pain that occurs in two months time. We can have chronic pain that occurs in eight months time. So we can't use the six months timeframe to differentiate between where we've got possibly the healing has occurred but we still have ongoing pain. It may be that it's never healed at all. So for example, chronic pain maybe a nonunion of a fracture is it's never really healed. But the patient could also have neck pains following three years after a slip and fall.

Currently, centers for disease, chronic pain is a leading cause of disability in the United States. We have several guidelines surrounding chronic pain in that section one of the ICD-9 medical coding guidelines. This is a good point that we need to have good accurate diagnosis code documentation so we can accurately report chronic pain. This is really important to educate our providers.

Well, coding pain is a specific diagnosis. If the pain is not documented or specified as acute or chronic, we should not assign codes from that category 338. There are a couple of exceptions for instance, post or economy pain, postoperative pain, neoplasm pain related to pain or central pain syndrome.

So if just have documentation of ankle pain due to slip and fall, we can't report acute pain. In contrast, acute ankle pain due to slip and fall, we can report acute pain due to trauma. So you can see how important it is our provider’s documentation so that we can accurately report their diagnosis.

Well, if that underlying definitive diagnosis is known, we drop back to what's that reason for the encounter. If the reason for the encounter is to treat that underlying condition, we're not even going to report the pain diagnosis codes. We're not going to report the 338 categories. However, if the reason is for pain control or pain management, then one of those codes from the subcategories 338.1 and 338.2 can be reported.

 So again, this is an education moment for our providers to accurately let us know what the reason is for that visit. Is it pain management versus treatment and management of that underlying condition?

Well, when we're going to report it as the first listed code? When it's the reason for that admission or encounter, that underlying cause of pain should be reported as an additional. And in the example, we've got an exacerbation of chronic SI joint plain. The assessment is chronic pain management of ankylosing spondylitis. They're going to do an SI joint injection to deal with that chronic pain. And so we're going to compliantly report the 338.29, other chronic pain as our primary or first listed.

Coding and Compliance Tip: When the admission or encounters for a procedure aimed at trading that underlying condition, then likewise, we're not going to report a code from 338. So we're not going to report acute pain. We're not going to report chronic pain. That pain would be considered integral to that underlying condition as being treated.

Codes from category 338 may be used in conjunction with codes that identify the site of pain. If the code describes the site of pain but does not fully describe or the pain is acute or chronic, then both codes should be assigned.

For example, acute left shoulder pain, so if we just had acute pain that doesn’t tell us the location, likewise, just left shoulder pain doesn’t tell us the differentiation of chronic or acute.

Postoperative pain: The acute code description is the default for both post or economy and other postoperative pains. This is one of the exceptions is that if our doctors just report post economy pain, our default is the acute. They don’t have to specifically document acute for these two.

We do have a medical coding guideline that specifically says routine or expected postoperative pain immediately after surgery should not be coded. We have some potential issues with assigning the 338.12 or 338.18 as the reason for the medical necessity for routine or planned.

Now, payer coverage policies may overrule these ICD-9 guidelines. So if they direct you to report one of the postoperative, acute postoperative pain codes for medical necessity for postoperative pain, then that payer written directive should be followed.

This goes back to complications, when it's associated with specific postoperative complications such as painful wire sutures. Maybe they've had an open heart surgery and they've cracked the sternum and they've used wire sutures to close that sternum together. And the patient may develop painful wire sutures. We're going to firs report the complication with that exception.

The exception is if the pain controller management is the reason for the service, then we're going to report the 338 postoperative pain code would be first listed. So again, we're draw back to what's the reason. If it's not associated with the specific postoperative complication, then we can assign appropriate category 338 postoperative pain.

Neoplasm pain: This is a common area for providers that take care of patients that have pain associated with their cancer or their cancer treatment. It is an area that the providers report that neoplasm is their primary or first link diagnosis. Well, that can be problematic when two providers sees a patient for the same diagnosis on the same date of service.

In the case of our pain management providers and providers that are taking care of that neoplasm related pain, they're not treating that cancer. They're and treating that malignancy. They're treating or taking care of the pain. And so, we need to have clear documentation.

So medical coding option 338.3 is going to be assigned regardless whether it's acute or chronic. And it's going to be the first listed when it's the admission or encounter is for pain control or neoplasm. And that's going to be very, very common. We should be reporting that 338.3 code for pain management of neoplasm pain.

In contrast to that last bullet is when they're managing, treating the neoplasm. That would more likely be our oncologist versus the pain associated with the condition.

Chronic pain syndrome, 37, I'd like to clearly address this. This is a common confusion between both billers and coders and sometimes also with providers, chronic pain syndrome. I want you to note what's that abbreviation. Well, it's CPS. Well, we also have another condition called central pain syndrome that also has the same abbreviation, CPS.

And so, we can't make that assumption that our providers when they document CPS is that that has anything to do with either one. We need to have further clarifications.

Chronic pain syndrome is a poorly defined condition. And we have a guideline that specifically says that they have to clearly document that chronic pain syndrome, that's the medical coding guidelines on 35 in order to accurately report it.

It's different than the term chronic pain. And it should only be used when the provider specifically documented chronic pain syndrome. So that diagnosis of chronic pain is not the same as chronic pain syndrome. It's also not the same as complex regional pain syndrome, CRPS. We really need to educate our providers on the importance.

In contrast, that central pain syndrome, it's also (thymic) pain syndrome, it's a very rare condition. It's when patients have had typically an injury to the central part of their brain. And they have typically pain on the side similar to a stroke. But instead of having paralysis, they have pain along one side of their body. So they may have pain in the right arm and right leg.

And so, that’s central pain syndrome. So be very cautious. That's reported with 338.0. In contrast, chronic pain syndrome is 338.4. For accurate medical coding and billing, it's very important to know the difference between and if your providers use CPS as an abbreviation to get them to clearly identify what they're meaning by CPS.

For more ICD-9 medical coding updates and information, visit our medical coding conference page.

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