Anesthesia Coding Alert

Tip: Don't limit yourself to just one ICD-9 code.

If you don't know what differentiates an acute condition from a chronic one, or how many diagnosis codes you can report, you could find yourself assigning the wrong code. Check out two common questions to get quick tips to help your pain management ICD-9 coding.

Do Injury Codes Apply to Pain?

Question 1: When can I report an acute injury ICD-9 code rather than a chronic injury code? We see patients for generalized pain (not necessarily a recent injury) and aren't sure what to code.

Answer 1: When coding some conditions, such as kidney disease (584.x and 585.x), you can often easily determine when the patient's condition is chronic because the diagnosis codes differ based on the patient's lab results. But coding for pain can be trickier.

For example, suppose your patient presents with shoulder pain, which came on slowly, that she says she has had for the past nine months. You consider 840.4 (Sprains and strains of shoulder and upper arm; rotator cuff [capsule]), but it is from ICD-9's "injury" chapter. In this case, the patient didn't have an injury -- instead she had nine months of pain. Therefore, you should avoid 840.4 and select another code based on the rest of your physician's documentation. You would most likely look for notes regarding the patient's signs and/or symptoms, such as 719.41 (Pain in joint; shoulder region) if your provider has not determined what's causing the patient's shoulder pain and has not given a definitive diagnosis. "Once a definitive diagnosis has been reached, you no longer code the symptoms," reminds Judith L. Blaszczyk, RN, CPC, ACS-PM, compliance officer with Auditing for Compliance and Education, Inc.

Why: Acute pain generally results from disease, surgery, inflammation, or injury. The pain is immediate and usually short-lived. Chronic pain, by contrast, typically persists beyond three to six months and can last from weeks to a lifetime. Chronic pain can originate with an initial trauma or injury but continues beyond the time of normal healing. Many practices use the "three months or longer" guideline for coding chronic pain conditions versus acute problems. "A definitive guideline has not been addressed by CMS, although it has identified coverage of electrical stimulation for chronic wounds as 'longer than one month,'" says Susan Vogelberger, CPC, CPC-H, CMBS, owner and president of Healthcare Consulting and Coding Education in Boardman, Ohio.

CDC Loosely Uses '3-Month' Guideline

Although not all payers or physicians follow this guideline, the Centers for Disease Control's National Center for Health Statistics publishes the following definition of an acute condition in its National Health Interview Survey:

"An acute condition is a type of illness or injury that ordinarily lasts less than three months, was first noticed less than three months before the reference data of the interview, and was serious enough to have had an impact on behavior."

Bottom line: Leave the determination of acute versus chronic to the physician. If an ICD-9 or CPT code forces you to differentiate between whether the patient's condition is acute or chronic, show both descriptors to the pain specialist and ask him to decide.

ICD-9 includes code family 338.xx for acute and chronic pain diagnoses. According to Section 1.B.6 of the ICD-9 Guidelines, however, don't assign codes from category 338.xx if you don't have an "acute" or "chronic" distinction. The only exceptions to this guideline lie with post-thoracotomy pain, postoperative pain, neoplasm related pain, or central pain syndrome. "If 'acute' or 'chronic' isn't specified, you need to look elsewhere for the code," Blaszczyk says.

How Many Diagnosis Codes Are 'Too Many'?

Question 2: Our pain specialist treated a patient with diabetes, but he was actually seeing the patient to treat a complication of the diabetes, diabetic polyneuropathy. During his evaluation,the physician also noted that the patient had shoulder joint inflammation. Should we report the neuropathy complication only or several ICD-9 codes to represent the patient's various conditions?

Answer 2: Normally, the primary diagnosis code that you list on your claim should represent the main reason for the encounter, or the condition with the highest risk of morbidity/mortality that the physician addresses during the visit. The situation changes, however, when you deal with a condition like diabetes.

According to Section 1.A.6 of the ICD-9-CM Official

Guidelines for Coding and Reporting, "Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the ICD-9-CM has a coding convention that requires the underlying condition be sequenced first followed by the manifestation.

"Should a patient have more than one manifestation of diabetes, more than one code from category 250 may be used with as many manifestation codes as are needed to fully describe the patient's complete diabetic condition," the Guidelines state.

Therefore, you should first report 250.6x (Diabetes with neurological manifestations). Remember to add a fifth digit to reflect the patient's type of diabetes and status of control. Your secondary code should represent the specific pain manifestation being treated. In this case, you should report 357.2 (Polyneuropathy in diabetes) as the secondary diagnosis. Because your pain practitioner documented joint inflammation, you should also report the appropriate code describing that condition (716.91, Arthropathy, unspecified; shoulder region).

Why so many codes: Although many payers will link only the first, main diagnosis code that you list to support the provided service's medical necessity, reporting all the diagnoses that follow the HIPAA-mandated guidelines is compliant coding. As of July 2007, Medicare must accept up to eight diagnoses for each electronic claim reported. The additional diagnoses might indicate more complex presenting problems and can provide the support you might need for a higher-level E/M service.