Home Health ICD-9/ICD-10 Alert

Don't list a 338.x code for postoperative pain due to a device left in the body.

The 2007 ICD-9 update brought new specificity for reporting a patient's pain with the 338 (Pain) category. But if you don't have a firm grasp of when it's appropriate to list these codes, your coding accuracy will suffer.

Know These Codes

First things first: If you're not aware of the pain management codes (new in 2007), they are as follows:

• 338.0 (Central pain syndrome);
• 338.1x (Acute pain);
• 338.11 (Acute pain due to trauma);
• 338.12 (Acute post-thoracotomy pain);
• 338.18 (Other acute postoperative pain);
• 338.19 (Other acute pain);
• 338.2x (Chronic pain);
• 338.21 (Chronic pain due to trauma);
• 338.22 (Chronic post-thoracotomy pain);
• 338.28 (Other chronic postoperative pain);
• 338.29 (Other chronic pain);
• 338.3 (Neoplasm related pain [acute] [chronic]); and
• 338.4 (Chronic pain syndrome).

Code The Reason For Care

The good news: The 338.x codes describe many different kinds of pain. But despite these expanded options, reporting one of these codes isn't appropriate for every patient who is experiencing pain.

For example, if the doctor has already made a definitive diagnosis, you cannot assign a code from 338.1x or 338.2x to describe the pain according to the ICD-9-CM Official Guidelines for Coding and Reporting, effective Nov. 15, 2006. The exception to the rule is when the reason for the encounter is pain control.

The right sequence: If the doctor made a de-finitive diagnosis, and the focus of the care is pain management, you should list the pain code first and the underlying condition second.

Coding example: Your patient has a history of uterine cancer for which she has received successful treatment. The current referral is for pain management of chronic pelvic pain related to the neoplasm that is affecting her ability to complete activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

For this patient, list the following codes, suggests Judy Adams, RN, BSN, HCS-D, with Larson-Allen in Charlotte, NC:

• M0230a: 338.3 (Neoplasm related pain [acute] [chronic]); and

• M0240b: V10.42 (Personal history of malignant neoplasm; genital organs; other parts of uterus).

Helpful: You may also use 338.x codes with codes that identify the site of pain, the guidelines say. For example, if your therapist is working with the patient to provide control of acute neck pain due to trauma, code 338.11 first, followed by 723.1 (Cervicalgia) to identify the pain site.

Take Note Of Acute And Chronic Descriptions

Before selecting a pain code, you must know whether the patient's pain is acute or chronic. The guidelines say that if the patient's pain is not specified as "acute" or "chronic," you may not assign codes with "acute" or "chronic" in the descriptors.

Exception: In the case of post-thoracotomy pain, postoperative pain or neoplasm-related pain, you may assign codes from the 338.x category, notes Marvel J. Hammer RN, CPC, CCS-P, ACS-PM, CHCO, of MJH Consulting in Denver, CO.

Sequence 338 Second For More Detail

You can also use the 338.x codes as secondary codes in three other instances: when you are addressing pain assessment, when pain impacts the plan of care associated with a thoracotomy or neoplasm, or with codes that identify the site of pain when the pain code provides more detail about the pain, Adams notes.

Sequencing tip: If the encounter is for something other than pain control, and the patient does not have a definitive diagnosis, assign the code for the specific site of pain first, and report the appropriate 338.x code second, guidelines say.

Coding example: To code cancer-associated pain, list 338.3 first when the reason for the encounter is pain management, and report the underlying neoplasm as an additional diagnosis.

On the other hand, if your focus is on managing the neoplasm itself, and the clinician happens to document pain associated with the neoplasm, you will code the neoplasm first and then 338.3 second as an additional diagnosis. 

Take note: The ICD-9 guidelines say to code 338.3 "regardless of whether the pain is described as acute or chronic."

Watch For Alternative Codes

When coding for pain, be sure you know when other coding options may be more appropriate than the 338.x codes. For instance, if a patient has postoperative pain associated with a device left in the body, you should turn to the "Injury and Poisoning" codes in chapter 17 of your ICD-9 manual, Adams says.

The guidelines also note that you should not code "routine or expected postoperative pain immediately after surgery."

Remember: The 338.x codes aren't appropriate when pain is integral to your patient's diagnosed condition. If the pain is a symptom of the patient's condition, code for the condition instead.

Coding example: Your patient has chronic venous insufficiency and a stasis ulcer of the ankle. She reports her pain as burning, tingling and shooting and says that it is present continuously. She rates the pain as a 10 on a scale of 1-10. For this patient, list the following codes, Adams suggests:

• M0230a: 459.81 (Venous [peripheral] insufficiency, unspecified); and

• M0240b: 707.13 (Ulcer of ankle).

Don't list a 338.x pain code for this patient because the pain is a symptom of chronic venous insufficiency, Adams explains.

Another trap: Use 338.4 only when your patient actually has chronic pain syndrome. This condition is different from "chronic pain," so this code should be used only when the provider has specifically documented this condition, the guidelines say.