Coding for Pain
Coding for Pain
This is a discussion of coding for Pain from the perspective of Orthopedic Surgery. In orthopedics, the single most common patient complaint is “pain.” However, “pain” is a "symptom," not a "disease." Pain is the manifestation of an underlying disease or problem, i.e. the “Pain” is caused by something else. There are a variety of types of pain: acute, subacute, chronic, localized, regional, traumatic, degenerative, psychogenic, neurologic, limb, joint, etc. For musculoskeletal "pain,” it can come from any of the tissues that compose the Musculoskeletal System: bone, joint, synovium, ligament, muscle and/or tendon, nerve, blood vessel, etc. The “Pain” from these tissues can originate from different disease processes such as infection, systemic or localized inflammatory disorder (Rheumatoid arthritis, gout, etc.), trauma, degenerative processes (such as osteoarthritis), and on and on. “Pain” can be localized such as a finger or toe, a specific joint, a specific region (neck pain, low back pain, etc.), and also more general or regional pain (arm and hand, hip and thigh, etc.). Then there are some people that hurt everywhere ("I hurt all over.").
Insofar as "Pain" is really a symptom, not a disease, it makes coding for pain quite difficult. The R Codes (R00-R99) are the codes that cover Symptoms and Signs of Disease. Code R52 is for "unspecified pain," but for ICD-10, "unspecified" codes should not be used unless absolutely necessary and/or completely unavoidable. Code R52 Excludes(1) acute and/or chronic pain NEC (G89. _); localized pain, unspecified type; and has a Coding Note to "code to pain” by site such as back, neck, joint, etc. (M Codes). These M Codes are called Site of Pain codes. The Instructions for the R Codes state that codes for symptoms (pain) should not be used except on a temporary basis when there is no definitive clinical diagnosis that explains the pain. A Site of Pain code should only be used temporarily or as a provisional code. They can be "carried over" as a diagnosis if the patient should disappear from care, and/or fails to proceed with recommended methods of evaluation (workup) that would probably determine the underlying diagnosis. Furthermore, once the underlying diagnosis is made, and if the patient's subjective pain is adequately explained by that diagnosis, then the Site of Pain code should “disappear” from the patient’s diagnosis list, and no longer used as a "primary" or "supplementary/complimentary" code to the underlying diagnosis code. For example, if a patient with knee pain is found to have a medial meniscal tear in the affected knee, then the diagnosis code for the medial meniscal tear would complete the necessary coding requirements in that it explains and/or includes the patient's pain. As such, a code for "knee pain,” would no longer be warranted.
In essence, using a Site of Pain code as a “Diagnosis” code doesn't really tell you anything as it is too vague and nonspecific. The M25.4 Code Set is for localized joint pain, but this Excludes pain in the hand and/or fingers, the foot and/or toes, limb pain, and spinal pain. "Limb pain" is covered by the Code Set M79.6 , which does include the arm, hand, and fingers; the thigh, leg, foot and toes. There is a code for Polyalgia, which applies to somebody who complains that they "hurt all over" However, Polyalgia is not the same as "Polyarthralgia" (for which there is no code in ICD-10), nor is it the same as "Polyosteoarthritis" of the M15 Code Set. Spinal "pain" problems are in the M54 Code Set: Dorsalgias (Back Pain), which also Includes radiculopathy and sciatica, but Excludes nerve pain/neuralgia, spondylopathies, and/or disc disorders with neurologic involvement. I am not quite sure why Radiculopathy (M54.1 ) and Sciatica (M54.3 ) are included in this Code Set, except that these are NOS (Not Otherwise Specified), i.e. there is no clear identifiable cause for the radiculopathy or the sciatica (i.e. disc, arthritis, spondylopathy, etc.).
Pain of neurologic origin (Neuritis, Neuralgia) are G Codes (G50-G59), but these codes generally Exclude traumatic nerve disorders and spinal causes of nerve pain or damage. It does Include Nerve Root and Plexus Disorders (with lots of Exclusions) and Mononeuropathies of the upper and lower extremities. These codes do Exclude Diabetic Neuropathy/Neuritis as well. There is a code, M79.2, for “unspecified neuralgia and neuritis,” which should probably not be used unless absolutely necessary because it is "unspecified,” and as you are aware, "unspecified" codes should not be used unless there is no true "diagnosis" explaining the "neuralgia and neuritis."
In the G Codes for the Nervous System there is the G89 Code Set for Pain, not elsewhere classified. These do Exclude(1) R52 for generalized pain and pain from psychological disorders. It also Excludes(2) the Site of Pain codes as previously discussed. However, this is an Excludes 2 situation such that if these particular types of pain coexist with another painful problem, then both can be reported and coded. There are some codes in this code set that could be quite useful in Orthopedics. G89.1 covers Acute pain, not elsewhere classified and includes G89.11: Acute pain due to trauma, and G89.18: Other acute post-procedural or postoperative pain. G89.2 covers Chronic pain, not elsewhere classified, which includes G89.21: Chronic pain due to trauma, and G89.28: Other chronic post-procedural or postoperative pain. There is a Coding Note for G89.28 which indicates that it cannot be used for the increased pain related to a postoperative complication. If there is a postoperative complication resulting in increased increased pain, the code for the complication from the T84 Codes should be listed first. There are some other codes in this G89 Code Set that would have some Orthopedic application, in particular G89.3: Neoplasm related pain, acute or chronic. This could be used for primary or metastatic bone tumor pain. Although not a truly Orthopedic problem, Chronic Pain Syndrome (G89.4), these patients are not rare in Orthopedic Surgery practice, but this is primarily a psychosocial dysfunction. There are some rules/caveats related to the use of G89 codes. These can be used in conjunction with other codes such as Site of Pain codes to add supplemental detail about the severity of the acute or chronic pain, but only if the pain fits one of the G89 categories as described above. Also, G89 Codes should not be used or listed primarily if the underlying diagnosis is known unless the reason for the Encounter is specifically for Pain Management, not for treatment of the underlying disease. In Pain Management the treatment for pain is primary and the G89 code would be listed first, and supplemented by the code from the underlying disease. This is also discussed in the next paragraph.
That leaves the question as to when and where can codes for “Pain" (Site of Pain) be used? As previously stated, they should be reserved and used only as a temporary or provisional diagnosis code until the true diagnosis, disease, or disorder causing the pain is identified. Unfortunately, and particularly as it relates to spinal pain problems (neck pain, upper back pain, low back pain, lumbosacral pain, etc.), sometimes a clearly identifiable underlying causative diagnosis cannot be made, and then the Site of Pain code has to be continued as the “Diagnosis” code. Also, a “Pain” (G89) code can be listed as a "primary" code if “Pain” is the main reason for a patient encounter, such as by a Pain Management Specialist, who might do an injection or other invasive procedure to treat the “Pain,” but not the underlying disease/cause of the pain. In that situation, the “first listed” code should be the “Pain” (G89) code, followed by the codes for the underlying diagnosis(es). For Orthopedic Surgeons, who are not doing “Pain Management,” a “Pain” code can be “first listed” if the reason for the patient encounter is for treatment of the pain, but not necessarily for the underlying disease. For example, if an Established Patient with known arthritis of the knee and a known and stable level of knee pain, comes in for evaluation and treatment of a recent increase in the severity of their pain (for whatever or no known reason, and without any new abnormal physical findings or x-ray findings to explain the increased pain), and a decision is made to do a steroid knee injection for relief of the pain, then the Site of Pain code for the Knee Pain (M25.56 ) could be used and “first listed” since the main reason for the visit is treatment of the pain, and followed by or supplemented with the code for their arthritis (M17.1 ).
The use of these "Pain” codes is probably justified in an Initial Evaluation of a patient in order to get the diagnostic process started. However, once a more specific diagnosis is made, that code should be used. It is my "gut" feeling that insurance companies/payers are probably not going to accept "Pain” codes as “Diagnosis” codes over a long period of time, or repeatedly, for payment of claims, or for the preauthorization or precertification of studies or procedures. If the patient has been adequately evaluated (worked up), and a specific diagnosis code has been determined, they will probably no longer except the "Pain” Code. In other words, they may help you get started, but they are not going to be accepted over the long haul.
Posted in Coding Blogs on Aug 25, 2016