# Additional references for coding acute on chronic pain



## trinalankford (Apr 30, 2015)

I am looking for additional references on coding acute on chronic pain.  I have read everything I can possibly find, Advance articles, many threads here, but I am just not grasping it.  Just when I think that I have it down, I have another coder in my department look at my codes, and they are incorrect, yet again 

If anyone has any articles that they have used to fully understand "acute on chronic pain" codes they would care to share with me, I would greatly appreciate it.  Here is a cut-and-paste I did from an AHIMA article.  I have bolded the part where I am hung up:

Use of Category 338 Codes with Pain Codes

Category 338 should be used in conjunction with site-specific pain codes (including codes from chapter 16) if category 338 codes provide additional information about the pain, such as if it is acute or chronic. The sequencing of category 338 codes along with site-specific pain codes (including chapter 16 codes) depends on the circumstances of the encounter or admission and must follow these guidelines:

?*If the encounter is for pain control or pain management, assign the category 338 code followed by the specific site of pain. *For example, an encounter for pain management for acute neck pain from trauma would be coded to 338.11 and 723.1.

?*If the encounter is for any reason other than pain control or management, and a related definitive diagnosis has not been established by the provider, assign the code for the specific site of pain followed by the appropriate code from category 338.* For example, an encounter for acute neck pain from trauma would be coded to 723.1 and 338.11.

I have two separate ER examples where "chronic back pain, unknown etiology," are established diagnoses:

1) First patient presents to the ER and is diagnosed with LS strain from repetitive movements in gardening. However, this patient also has a diagnosis of chronic LS back pain. I had it coded as the LS strain primary (reason for visit) but the chronic pain code secondary and low back pain as my third diagnosis (to further delineate the chronic pain which does not have an etiology).

2) Second patient presents with a simple exacerbation of his back pain. He does not have an established etiology for his chronic back pain and presents because his chronic meds are not controlling his pain.  This one would fall under the first example above, where the 338 code would be primary because of the reason for visit and the back pain would be secondary...correct?

If you've read this far, thank you for bearing with me, but I am struggling with these pain codes, and I believe I'm making it much more difficult than it should be.

Thank you so much for your time!


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## em2177 (Apr 30, 2015)

Here is a reference from AHIMA and the coding clinic:
http://campus.ahima.org/audio/2007/RB111307.pdf


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## mitchellde (Apr 30, 2015)

In case #1 the patient presents with an acute back strain, the lumbago code and the chronic pain code are not a part of this encounter, and the guidelines state that you do not code the symptom code when a definitive dx has been rendered.  The provider indicates low back strain, therefore you would not code the lumbago at all, and since the visit was for diagnosis and treatment of the condition now diagnosed as back strain you would not use the 338 code as it was not a visit for pain management.
For case number 2 you cannot use a 338 code unless the provider documents that the pain is acute or chronic.  The coder may not assume the acute or chronic status expect for post op pain which defaults to acute unless documented as chronic.


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## trinalankford (Apr 30, 2015)

Thank you both for your help.

In other words, the only time I would code the chronic back pain (338 series) is:

1) If it is a secondary diagnosis, i.e., patient presenting with something else but has chronic pain in his PMH but is on maintenance meds FOR that pain (Lidoderm patch, methadone, morphine, any of a gazillion other pain killers), "chronic pain 338" is coded because those chronic meds will have a bearing on the management of whatever it is they are presenting for...

2) MD states "chronic" site-specific pain but there is no known cause for it, necessitating the use of a 338 code plus site-specific pain code...

3) MD states "chronic" site-specific pain and the reason for the encounter is pain control/management and not management of any underlying condition.  I do understand the "management of an underlying condition" (placement of neurostimulator, surgery for spinal stenosis, etc.).  It is the encounter aimed at pain control/management that is getting me, because in my brain, all of the encounters pertaining to the pain would be aimed at pain control in some way, shape, or form.

I have a quote from an Advance article that states, "If the encounter is for any reason other than pain control or management, and a related definitive diagnosis has not been established, assign the code for the specific site of pain followed by the appropriate code from category 338; for example, an encounter for acute back pain from trauma would be coded to 724.5 and 338.11."  Is the use of 338.11 ONLY because the word "acute" appears in that diagnosis?



> For case number 2 you cannot use a 338 code unless the provider documents that the pain is acute or chronic. *The coder may not assume the acute or chronic status* expect for post op pain which defaults to acute unless documented as chronic.


 I do understand that part, also.

I apologize for my stupidity, and I thank you for your help.


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## trinalankford (Apr 30, 2015)

I'm going to add/change something in my prior examples, just for additional scenarios:

1) Patient #1 presents to the ER with "LS strain from repetitive movements in gardening." However, this patient also has a diagnosis of chronic LS back pain. 

Because the word "acute" did not appear in the diagnosis, I'm thinking the only diagnosis code in this case is 846.0 LS sprain, no diagnosis to account for the "history of" chronic back pain. The reason I'm wanting to code the history of chronic back pain, I think, is because of the "acute on chronic pain." Is the simple 846.0 alone correct in this case?

2) Patient #2 presents with dx of "LS back pain with exacerbation of *chronic* low back pain." There is no established etiology for this chronic back pain, and he presents because his chronic meds are not controlling his pain. 

Would the 338 code would be primary because of the reason for visit and the back pain would be secondary, or is a 338 code not appropriate even in this scenario? With his chronic meds not controlling his pain, this is obviously the reason for the visit and, thus, my logic.

Again, thanks for your help!


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