Neurosurgery Coding Alert

Question: How should I assign a diagnosis if the patient's primary complaint is "back pain"? I am new to neurosurgery coding and see this quite often.

Virginia Subscriber

Answer: When you are seeking a pain diagnosis, you should try to identify as precisely as possible the pain's location and/or source. If pain is the primary symptom and you know the location, a quick look at the "Index to Diseases" at the front of your ICD-9 manual will generally provide all the information you need.

Example: The patient has low back pain as his primary complaint. By referencing "pain" in the ICD-9 index and following it to location "back: low," you will find 724.2 (Lumbago). Checking this against the tabular listings, you confirm the 724.2 diagnosis, which includes low back pain, low back syndrome, and lumbalgia, according to notes in the ICD-9 manual.

Typical "pain" complaints you may see in neurosurgery practice include 724.2, as well as sacroiliac pain (724.6), pain of the thoracic spine (724.1), unspecified backache (724.5), and possibly headache (784.0).

Remember: After the surgeon has identified the cause of the pain, you should use the more specific diagnosis or condition, rather than the signs and symptoms (including pain) that prompted the patient to visit the surgeon. For instance, if the surgeon has confirmed a diagnosis of sciatica to explain the patient's lower back pain, you should turn from 724.2 to 724.3 (Sciatica).