# coding acute and chronic pain



## jtjohnson

I am struggling with coding the icd.9 for the facility. If a patient is dx with
acute on chronic low back pain, how do you code it? I have just been coding 724.2 with 338.29 but I wonder if I should also use the 338.19? Help?


----------



## klemkosky

Maybe this will help- I often refer to this ( I got out of the ADVANCE MAGAZINE) maybe it will help you as well.


Vol. 18 •Issue 1 • Page 8 
CCS Prep! 
Pain Codes Don't Have to Be Painful 
This month's column provides an overview of the pain codes and the revised coding guidelines. 
Prepared by Ingenix Staff 
The coding of encounters for pain traditionally has been confusing to coders. New pain codes were created effective Oct. 1, 2006, for reporting categories and causes of pain. Previously, codes for pain were limited to the specific anatomic sites of pain and did not provide a mechanism to report codes for pain management encounters or for particular types of pain. The coding guidelines for reporting these pain codes were revised effective Oct. 1, 2007. This column provides an overview of the pain codes and the revised coding guidelines. 
Category 338, Pain Not Elsewhere Classified: 
•  338.0, Central pain syndrome 
•  338.1X, Acute pain 
•  338.2X, Chronic pain 
•  338.3, Neoplasm-related pain (acute) (chronic) 
•  338.4, Chronic pain syndrome 
•  780.96, Generalized painâ€“used when the site of the pain is not specified 
General Coding Information 
Codes in category 338 may be used in conjunction with other codes to provide more detail about acute or chronic pain and 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, neoplasm-related pain or central pain syndrome. 
In general, a code from subcategories 338.1 and 338.2 should not be assigned if the underlying diagnosis is known, unless the reason for the encounter is pain control/management and not management of the underlying condition. 
Category 338 codes are acceptable as principal diagnosis or the first-listed code in the following circumstances: 
•  When pain control or pain management is the reason for the encounter. 
•  When an encounter is for a procedure aimed at treating the underlying condition, a code for the underlying condition should be assigned as the principal diagnosis. No code from category 338 should be assigned; for example, when a patient is admitted for a kyphoplasty for spinal stenosis. 
•  When a patient is admitted for the insertion of a neurostimulator for pain control, assign the appropriate pain code as the principal or first-listed diagnosis. When an admission or encounter is for a procedure aimed at treating the underlying condition and a neurostimulator is inserted for pain control during the same admission/encounter, a code for the underlying condition should be assigned as the principal diagnosis and the appropriate pain code should be assigned as a secondary diagnosis. 
Central Pain Syndrome 
Central pain syndrome, 338.0, is a neurological condition caused by damage to or dysfunction of the central nervous system. This syndrome can be caused by stroke, multiple sclerosis, tumors, epilepsy, Parkinson's disease or may be caused by brain or spinal cord injuries. The pain associated with this syndrome differs widely. Central pain syndrome often begins shortly after the condition arises or injury occurs, but may be delayed by months or even years, and may affect a large portion of the body or may be more restricted to specific areas, such as hands or feet. Pain is typically constant. The following syndromes are coded to 338.0: Dejerine-Roussy syndrome, and myelopathic pain syndrome; Dejerine-Roussy syndrome; Myelopathic pain syndrome; and Thalamic pain syndrome (hyperesthetic). 
Acute and Chronic Pain 
Acute pain typically begins suddenly. It can range from mild to severe and may last a few minutes or a few weeks. Chronic pain lasts for weeks or months. Acute pain disappears when the pain's underlying cause is identified and treated. Acute pain may be caused by surgery, fractured bones or other injuries 
Acute pain codes: 
338.11, Acute pain due to trauma 
338.12, Acute post-thoracotomy pain 
338.18, Other acute postoperative pain 
338.19, Other acute pain 
Unrelieved acute pain may lead to chronic pain, which may persist even though the underlying injury has healed. 
Chronic pain codes: 
338.21, Chronic pain due to trauma 
338.22, Chronic post-thoracotomy pain 
338.28, Other chronic postoperative pain 
338.29, Other chronic pain 
There is no time frame defining when pain becomes chronic pain. The physician's documentation should be used to deter-mine the assignment of these codes. If chronic or acute pain cannot be determined, the default is acute pain. 
Common chronic pain complaints include headache, low-back pain, cancer pain, arthritis pain, neurogenic pain (pain resulting from damage to the peripheral nerves or to the central nervous system itself), psychogenic pain (pain not due to past disease or injury or any visible sign of damage inside or outside the nervous system). 
Because of the complex etiology and the frequent presence of associated disorders involved in chronic pain, a detailed review of the musculoskeletal, reproductive, gastrointestinal, urologic and neuropsychological systems must be obtained. The history should include the pain location, duration of the pain, precipitating and alleviating factors and the severity or intensity of the pain. 
Postoperative Pain 
Postoperative pain is classified to subcategories 338.1 and 338.2, depending on whether the pain is acute or chronic. The default for postoperative pain not specified as acute or chronic is the code for the acute form. 
It is important to note that routine or expected postoperative pain immediately after surgery should not be coded. When postoperative pain is not associated with a specific postoperative complication, it is assigned to the appropriate postoperative pain code in category 338. 
However, pain associated with devices, implants or grafts left in a surgical site or due to a specific postoperative complication is assigned to the appropriate code in Chapter 17, Injury and Poisoning. Use additional codes from category 338 to identify acute or chronic pain (338.18-338.19 or 338.28-338.29). 
Postoperative pain associated with a specific postoperative complication is also assigned to the appropriate code found in Chapter 17. For example, complication from a device left in the body is coded to 998.4, Foreign body accidentally left during a procedure. If appropriate, use additional codes from category 338 to identify acute or chronic pain such as 338.18 or 338.28. 
Postoperative pain may be reported as the principal diagnosis when the reason for the encounter is postoperative pain control management. It may also be assigned as a secondary diagnosis code when the patient presents for outpatient surgery and develops an unusual or inordinate amount of postoperative pain. 
Neoplasm-related Pain 
Code 338.3 is assigned to report pain documented as being related, associated or due to cancer, primary or secondary malignancy, or tumor. This code is assigned regardless of whether the pain is acute or chronic. 
If the admission is for control of pain related to the malignancy, assign code 338.3. The underlying neoplasm should be reported as an additional diagnosis. 
When the encounter is for management of the neoplasm and the pain associated with the neoplasm is also documented, it is appropriate to assign code 338.3 as an additional diagnosis. For example, a patient is seen because of lower back pain; the patient has breast cancer, and a bone scan shows metastasis to bones. The encounter would be coded to 198.5, 174.9, and 338.3. 
Chronic Pain Syndrome 
Chronic pain syndrome, 338.4, is prolonged, persistent pain that significantly interferes with the patient's ability to function in life. Anxiety, depression and anger are often present because of the stress that the pain puts on the patient. Chronic pain syndrome should not be confused with chronic pain. Code 338.4 should only be used when the physician has specifically documented this condition. 
Site-Specific Pain Codes 
Category 338 should be used in conjunction with site-specific pain codes 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 depends on the circumstances of the encounter or admission as follows: 
•  If the encounter is for pain control or management, assign the category 338 code followed by the specific site of pain. For example, an encounter for pain management for acute back pain from trauma would be coded to 338.11 and 724.5. 
•  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. 
Review the coding guidelines and all Coding Clinic references and take the following quiz to test your knowledge of assigning the pain codes. 
1. The patient is admitted for diagnostic work-up to identify the etiology of excruciating disabling lower back pain with severe pain in both lower extremities. The lower back pain radiated to the lower extremities and was associated with numbness. The final diagnostic statement lists chronic pain syndrome and chronic lower back pain with acute exacerbation of lower back pain and lower extremity pain. What is the appropriate way to code and sequence these diagnoses? 
a.724.2, 729.5, 338.4, 338.19 
b.338.19, 338.4, 724.2, 729.5 
c.338.4, 338.19, 724.2, 729.5 
d.724.5, 729.5, 338.4, 338.19 
2. The patient is admitted for pain management of excruciating disabling lower back pain. The physician states that the pain was related to a motor vehicle accident that the patient had been involved in several years ago. The final diagnostic statement lists chronic pain syndrome and chronic lower back pain. What is the appropriate way to code and sequence these diagnoses? 
a.724.2, 338.4, 338.19 
b.338.4, 724.2 
c.724.2, 338.4 
d.724.5, 338.4 
3. A patient is seen in the emergency department to evaluate acute knee pain after recent knee replacement surgery. An X-ray is performed and the discharge diagnosis is documented as pain due to knee replacement. The patient is given pain medications to alleviate the pain and discharged home with the instructions to make an appointment with his physician. What is the appropriate way to code and sequence these diagnoses? 
a.996.77, 338.18, V43.65 
b.338.18, 996.77, V43.65 
c.996.77, V43.65 
d.338.18, V43.65 
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace. 
Coding Clinic is published quarterly by the AHA. 
CPT is a registered trademark of the AMA. 




Answers to CCS PREP!: 1. a: Assign code 724.2, Lumbago, for the lower back pain as the principal diagnosis. Assign codes 729.5, Pain in limb, for the pain in both lower extremities, 338.4, Chronic pain syndrome, and 338.19, Other acute pain, for the acute exacerbation as additional diagnoses. The low back pain was sequenced as the principal diagnosis since it was the reason for the admission; 2. b: Assign code 338.4, Chronic pain syndrome, as the principal diagnosis because the patient was admitted for pain control. Code 724.2, Lumbago, for the lower back pain is an additional diagnoses; 3. a: 996.77, Other complications due to internal joint prosthesis, is assigned as the principal diagnoses to identify the pain due to the patient's recent knee replacement. Code 338.18, Acute postoperative pain and V43.65, Knee replacement status, are assigned as additional diagnoses.


----------

