# Pain Management Coding



## abs1821 (Jan 10, 2014)

I just started billing for a billing company that's starting from the ground up.

Our providers are pain management dr's and my question is on the superbills they list their diagnosis but do not list what's primary, secondary etc.  My director seems to think that what order they go in is not important but I feel like it is to a degree but I can't prove this and I have run out of places to look.

I have always billed for Chiropractic offices so this is a learning experience for me.  I know in our office if we billed a level 3 exam 99213 we had to also have enough dx codes to prove why that level of an exam was necessary.

I hope this isn't confusing but my brain is all over the place right now and I need just the general direction of where to look to find these answers.


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## OCD_coder (Jan 10, 2014)

HIPAA rules state we should be following the guidelines as they are written in the CPT, ICD-9 and HCPCS manuals.  Your directions on what codes should be primary, secondary are outlined in detail at the beginning of your ICD-9 book.  But here is a very basic breakdown of the thinking process, I direct you and anyone else to read the guidelines for more explicit details/directions.  

Select diagnosis codes for the highest acuity first, followed by chronic conditions/diseases. Acute over chronic.  You do not use  Dx codes for signs/symptoms when a definitive diagnosis is available.  Understanding the disease process is necessary as you need to understand symptoms that are considered inclusive to the disease process.

Tip:  Brush up on LCD/NCD's by your local MAC carrier as some MAC's have pain management guidelines for procedures.  This will also help with how to select what code for clean claims.

Example:
Patient has a herniated disk at the L4 level, so lumbar pain would not be used.  But if the patient has cervical pain without a definitive diagnosis yet, this would be listed second.


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## mitchellde (Jan 11, 2014)

abs1821 said:


> I just started billing for a billing company that's starting from the ground up.
> 
> Our providers are pain management dr's and my question is on the superbills they list their diagnosis but do not list what's primary, secondary etc.  My director seems to think that what order they go in is not important but I feel like it is to a degree but I can't prove this and I have run out of places to look.
> 
> ...


If the reason for the encounter is pain management then you need a pain code first listed.  For ICD-9 CM this would be a 338, for ICD-10 CM it is G89 catergories.  The guidelines can walk you through when to use these and what codes are listed secondary.  Just be sure the therapy/drug is specifically for pain control.


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## abs1821 (Jan 13, 2014)

I reviewed the front of the book and that was helpful and a lot of our patient's are being seen for chronic pain.

Another question is...would the same dx listed for the office visit be correct for the injection??


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## dwaldman (Jan 13, 2014)

Your second question is the same diagnosis for the office visit, going to correspond with the injection diagnosis link. An important thing that you want to look at it is. Is there a separately identifiable office visit from the decision to perform an injection. Does the previous note state that this encounter was planned injection. You would only want to add the modifier 25 if the office visit was not the decision to perform the injection, that the patient condition required additional Evaluation and Management services that went above and beyond required to perform the procedure. 

With the practice I work at we not bill office visit in addition to injections. If injection is performed then that is the of billed only. 

In determing the sequencing of the diagnoses/ICD-9 codes and what are related to the procedure, you need to move away from working from the superbill, and need to look at the medical record and look at the impression of what the physician states is the patient medical conditions that are relevant to that visit and do those appear Chief Complaint, HPI and is there medical management of those conditions. Or are they underlying medical conditions such as hypertension or diabetes that might require referral back to the patient's PCP or other specialist.

When reviewing the plan of care or HPI, the physician will spell out what is the condition that dominates the visit and should be sequenced first. Such as the patient back pain is still with current medication but knee is causing the most trouble. Is the knee pain addressed in the HPI or chief complaint. 

I would review with the director that the sequencing of the diagnoses is important but again those conditions and sequencing needs to come from the medical record not a superbill that is not the formal medical record. 

Another thing to consider is sign and symtoms of other conditions would not be separately coded. Many physicians will select lumbar radiculopathy and Lumbar disc displacement and then correlate that the radiculopathy is due to the displaced disc. But they select in EHR or dictated note as separate condtions 724.4 722.10. What they have to be educated on is they have to state if the sign or symptoms such as back pain, sciatica, facet syndrome are due to spinal conditions such as spondylosis, disc degeneration, disc displacement, or spondylothesis.

Like the previous post you received,  they can also document the patient has chronic pain or chronic pain syndrome. Then might list conditions like post laminectomy syndrome which can be sequenced as a secondary diagnosis to display the location of the pain.

Lastly, if the concern is you want to better sequence the diagnosis to capture the most accurate picture of the encounter and the patient's condition. You can write a letter stating the plan of care or HPI needs to indicate what is the patient primary pain generator for accurate and timely application of the primary diagnosis.


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