ED Coding and Reimbursement Alert

338 series unveiled to represent acute, chronic pain

ED coders now have a host of new diagnosis codes to add to their claims, thanks to the beefed up ICD-9 manual for 2007.

Since October 1, when the codes took effect, ED coders have had the option of representing their patients- acute and chronic pain complaints with new diagnosis codes from the 338 code series. But there are very specific instances in which you should actually use the new codes, experts say.

-The pain codes are to define unspecified pain areas or to be used as secondary codes to specify the condition and cause of the pain,- explains Debra Tyx,  RHIT, coding manager at PBS Inc., in Amherst, N.Y.

Report 338 Codes as Secondary Diagnoses

According to Michael Granovsky, MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass., the new pain codes in ICD-9 2007 that ED coders will be most interested in are:

- 338.11 -- Acute pain due to trauma

- 338.12 -- Acute post-thoracotomy pain

- 338.18 -- Other acute postoperative pain

- 338.19 -- Other acute pain

- 338.21 -- Chronic pain due to trauma

- 338.28 -- Other chronic postoperative pain

- 338.29 -- Other chronic pain

Important: Most of the time, you-ll use the 338 codes -in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain,- explains Granovsky. In the ED, you could use these codes in conjunction with chapter 16 and chapter 17 diagnosis codes. Many of these codes are very general in their descriptions, with the exception of 338.12, which you-d use only to report post-thoracotomy pain.

What's the difference between acute and chronic pain? According to Tyx, -acute pain is new to the patient. Chronic pain is not new to the patient -- this could be from a week-old pain to the last 30 years of persistent pain.- If the patient does not describe chronic or acute pain, leave 338 codes off the claim.

Consider this example: A patient who had left hip surgery 10 days ago reports to the ED. The physician performs a level-3 E/M service, during which time the patient says she has recently experienced pain in her left hip. On the claim, you should:

- report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity) for the E/M service.

- attach 719.45 (Pain in joint; pelvic region and thigh) to 99283 as the primary diagnosis.

- attach 338.18 to 99283 as the secondary diagnosis.

Here are a few ailments an ED patient might have that, depending on the presentation, might be accompanied by a 338 chronic pain code as a secondary diagnosis: fibromyalgia, reflex sympathetic dystrophy and other chronic pain syndromes.

There are also instances where the 338 pain codes might be used as primary diagnoses. If pain management is the reason for the encounter, you might report the pain code first, Granovsky explains.

Consider this example:  A patient presents complaining of an exacerbation of chronic foot pain that he has had for 2 years following a severe crush injury by a steam roller. To date, a full work-up has been negative, and the patient is under the care of a pain management specialist. The coder now has a helpful tool to report the reason for this visit.

In this case, you should report 338.21 as the primary diagnosis along with the E/M code.

Warning: Since the 338 pain codes are new, and the claims experience is still evolving, some insurers may be hesitant to accept them as primary codes.

-The reimbursement reality is that these are new codes, and although they are effective as of October 1, 2006, many payers are slow to add the new code into their systems,- Granovsky explains. So you should code accurately, but check your large payers to make sure they have updated their systems and review explanations of benefits (EOBs) on the back end to make sure your claims are appropriately reimbursed.

Add a V Code If Physician Removes Patient's Sutures

While the 338 series pain codes are the most important changes in ICD-9 2007, there are some other new diagnosis codes that you-ll be interested in. Here is a list of the other new ICD-9 codes that Granovsky thinks ED coders should be aware of:

- 288.60 -- Leukocytosis (Elevated white blood cell count) unspecified

- 478.19 -- Other diseases of nasal cavity and sinuses

- 519.11 -- Acute bronchospasm

- 649.53 -- Spotting complicating pregnancy; antepartum condition or complication

- 780.96 -- Generalized pain

- 780.97 -- Altered mental states 

- 784.91 -- Postnasal drip

- 995.20 -- Unspecified adverse effect of unspecified drug, medicinal and biological substance

- 995.23 -- Unspecified adverse effect of insulin

- 995.27 -- Other drug allergy

- 995.29 -- Unspecified adverse effect of other drug, medicinal and biological substance

- V58.30 -- Encounter for change or removal of nonsurgical wound dressing

- V58.31 -- Encounter for change or removal of surgical wound dressing

- V58.32 -- Encounter for removal of sutures.