29, 2007

Coding for Pain
For The Record
Vol. 10 No. 11 P. 38

Effective October 1, 2006, ICD-9-CM category 338 was created for pain. The following are the new codes in category 338:

• 338.0, Central pain syndrome;

• Dejerine-Roussy syndrome;

• Myelopathic pain syndrome;

• Thalamic pain syndrome (hyperesthetic);

• 338.11, Acute pain due to trauma;

• 338.12, Acute postthoracotomy pain;

• Postthoracotomy pain not otherwise specified (NOS);

• 338.18, Other acute postoperative pain;

• Postoperative pain NOS;

• 338.19, Other acute pain;

• 338.21, Chronic pain due to trauma;

• 338.22, Chronic postthoracotomy pain;

• 338.28, Other chronic postoperative pain;

• 338.29, Other chronic pain;

• 338.3, Neoplasm related pain (acute) (chronic);

• Cancer-associated pain;

• Pain due to malignancy (primary) (secondary);

• Tumor-associated pain;

• 338.4, Chronic pain syndrome; and

• Chronic pain associated with significant psychosocial dysfunction.

Code 780.96, Generalized pain, was also created to identify unspecified pain.
Acute vs. Chronic Pain

Acute pain typically begins suddenly and is usually a sharp feeling. It can range from mild to severe and may last a few minutes or a few weeks or months. However, acute pain does not typically last longer than six months. It disappears when the pain’s underlying cause is identified and treated. Acute pain may be caused by surgery, fractured bones, dental work, burns or cuts, or labor/childbirth.

Unrelieved acute pain may lead to chronic pain, which may persist even though the underlying injury has healed. Common effects of chronic pain include tense muscles, limited mobility, lack of energy, change in appetite, depression, anger, or anxiety.

Coding Guidelines for Pain

The **ICD-9-CM Official Guidelines for Coding and Reporting## were updated, effective November 15, 2006, with a new section for the proper sequencing and usage of the pain codes (**AHA Coding Clinic for ICD-9-CM,## 2006, fourth quarter, pages 167-172). The following is a summary of the guidelines.

It is appropriate to assign other codes with codes from category 338 to further describe the acute or chronic pain and the neoplasm-related pain. “If the pain is not specified as acute or chronic, do not assign codes from category 338, except for postthoracotomy pain, postoperative pain, or neoplasm related pain” (pages 167-168).

Do not assign a code from subcategories 338.1 and 338.2 if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control/management and not management of the underlying condition.

A code from category 338 should be sequenced as the principal diagnosis when:

• The related definitive diagnosis has not been established by the physician.

• The reason for admission is for pain control or pain management.

It is appropriate to assign a code from category 338 with another site-specific code if the code from category 338 provides additional information. Sequencing of these two codes will depend on the circumstances of admission with the following two exceptions.

If the reason for admission is for pain control/management, then the code from category 338 is sequenced as the principal diagnosis followed by the site-specific pain code.

If the reason for admission is for any reason other than pain control/management and a related definitive diagnosis has not been established, then the site-specific pain code will be sequenced as the principal diagnosis with the code from category 338 sequenced as a secondary diagnosis.

Pain due to a device or foreign body left in a surgical site is not assigned to category 338. Instead, assign the appropriate code from Chapter 17, “Injury and Poisoning.” However, if the patient was admitted for pain control/management because of pain due to a device or foreign body left in a surgical site, then a code from category 338 is assigned and sequenced as the principal diagnosis.

Postoperative pain and postthoracotomy pain not specified as acute or chronic defaults to the code for the acute type. Sequence the postoperative pain code as the principal diagnosis when the patient is admitted for postoperative pain control or pain management. Sequence the postoperative pain code as a secondary diagnosis when the patient develops an “unusual or inordinate amount of postoperative pain” after outpatient surgery. Do not assign a code for the postoperative pain if it is routine or expected after surgery.

There is no time frame that identifies when the pain can be defined as chronic. Code assignment is based on the physician’s documentation.

Neoplasm-related pain (338.3) is for pain due to, related to, or associated with primary or secondary malignancy or tumor, regardless if the pain is acute or chronic. Code 338.3 is sequenced as the principal diagnosis when the patient is admitted for pain control/management. If the patient is admitted for management of the neoplasm and pain is also documented, code 338.3 may be sequenced as a secondary diagnosis.

The diagnosis of chronic pain syndrome is not the same as chronic pain. Assign the code for chronic pain syndrome only when that diagnosis has been documented by the physician.

Coding and sequencing for pain are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific **AHA Coding Clinic for ICD-9-CM## and American Medical Association **CPT Assistant## references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.