Cracking the Code
The ICD-10-CM guidelines for this coding area include the proper code selection and sequencing for pain. This chapter includes acute and chronic pain, postoperative pain, pain associated with neoplasms, and chronic pain syndrome.
When selecting a pain code, we need to know if the pain is acute or chronic. Unless the patient presents for pain management, including insertion of a neurostimulator for pain control, code the underlying condition causing the pain instead of a code from category G89. If the encounter is for pain management, we would select a code from category G89 followed by the code that identifies the underlying condition. An additional code can also be reported to identify the site of the pain when applicable.
When the encounter is to treat the underlying disease, even if a neurostimulator is inserted, two codes are required. First, select the code for the underlying condition, followed by the pain code.
Coding postoperative pain is based on the provider’s documentation. Routine or expected postoperative pain immediately after surgery is not coded. Postoperative pain not specified as acute or chronic is coded as acute. There are times when postoperative pain is associated with a specific complication. When the pain is associated with a specific complication, the code for the complication is primary with a code from category G89 reported secondarily. Now when the pain is not associated with a specific complication, a code from category G89 is reported.
Coding for Chronic pain is reported with a code from subcategory G89.2 and is based on the provider’s documentation that the pain is chronic. There are no specified clinical parameters to indicate when pain is acute or chronic. Central pain syndrome (G89.0) and chronic pain syndrome (G89.4) are different than chronic pain. These conditions should only be coded when the documentation specifically identifies these conditions.