Oncology & Hematology Coding Alert

Hint: Begin by carefully reading ICD-10-CM guidelines.

The G89 (Pain, not elsewhere classified) codes aren’t as easy to assign as they seem. While most everything you need to know before coding G89.3 (Neoplasm related pain (acute) (chronic)) can be found in ICD-10-CM guideline I.C.6.b.5, sometimes putting that guidance into practice can be a little tricky.

That’s why we’ve put together this guide to give you a foolproof way to apply G89.3 the next time a patient with cancer-related pain comes into your office. But make sure you read to the end, as sometimes payers can override these guidelines and create a whole different kind of pain for you.

Apply G89.3 for Pain Regardless of Cancer Type or Duration

The first important element of the guideline helps you understand what kind of neoplasm-related pain G89.3 describes. Importantly, you can use the code for pain associated with “cancer, primary or secondary malignancy, or tumor,” meaning that the pain can be the result of both malignant and benign neoplasms. You can see this in the list of inclusion terms under G89.3, which adds “tumor associated pain” to “cancer associated pain” and “pain due to malignancy (primary) (secondary).”

Further, as the code descriptor indicates, you can use the code “regardless of whether the pain is acute or chronic” per the guideline. This means you and your provider can assign the code no matter whether you apply the National Cancer Institute definition of a chronic disease as “a disease or condition that usually lasts for 3 months or longer” (www. cancer.gov/publications/dictionaries/cancer-terms/def/chronic-disease), or the Centers for Disease Control and Prevention’s (CDC’s) definition of a chronic diseases as “conditions that last 1 year or more” (www.cdc.gov/chronicdisease/about/index.htm).

Sequence G89.3 per Encounter Reason

“When pain control or pain management is the reason for the admission/encounter,” you’ll use G89.3 as the first-listed code, and “the underlying cause of the pain should be reported as an additional diagnosis, if known,” explains Jessica Miller, MHA, CPC, VP revenue cycle at Ortmann Healthcare Consulting Services in South Carolina.

This follows the next directive found in ICD-10-CM guideline I.C.6.b.5, which tells you the code “may be assigned as the principal or first-listed code when the stated reason for the admission/encounter is documented as pain control/pain management. The underlying neoplasm should be reported as an additional diagnosis.”

However, the guideline goes on to tell you that “when the reason for the admission/ encounter is management of the neoplasm and the pain associated with the neoplasm is also documented, code G89.3 may be assigned as an additional diagnosis. It is not necessary to assign an additional code for the site of the pain,” though there is nothing prohibiting you from doing so.

But when an admission or encounter is for a procedure aimed at treating the underlying condition, assign a code for the underlying condition as the principal diagnosis and no code from category G89, according to Miller.

Put it All Together With This Case Study

A patient reports to your oncologist with prostate cancer, which has metastasized to the femur. Both cancers are currently active and being treated. The patient recently fractured their femur and has been prescribed an opioid for pain management. The femur is healing normally.

How you would code this depends on the primary purpose of the encounter.

For pain management of the fractured femur: If the patient’s chief complaint is pain resulting from the fracture, begin with G89.3, adding M84.551D (Pathological fracture in neoplastic disease, right femur, subsequent encounter for fracture with routine healing) for the fracture. As the fracture is a direct result of the secondary cancer, you can then report C79.51 (Secondary malignant neoplasm of bone) and C61 (Malignant neoplasm of prostate) for the active cancers. And you’ll finish the diagnosis code sequence with Z79.891 (Long term [current] use of opiate analgesic) to indicate the patient is undergoing opioid treatment for the fracture pain.

For treatment of the primary or secondary neoplasm with pain documentation: If the patient is reporting for treatment of either the prostate cancer or the metastatic bone cancer and is still reporting pain from the fracture, but the oncologist does provide treatment to manage the pain at the encounter, you should lead with C79.51 or C61, sequencing first the cancer being treated. You can add G89.3 to the sequence if the fracture pain is documented.

For treatment of the primary or secondary neoplasm with no pain documentation: In this case, you should report only the cancer being treated. Code G89.3 is neither needed nor appropriate in this situation.

And Remember: Not all Payers Recognize Primary G89.- Dx

There are still some payers that don’t recognize G89.- codes as primary diagnoses, even when the rules call for it to be coded first. In these instances, Miller says you should do what the payer policy or Medicare Administrative Contractor’s (MAC’s) local coverage determinations (LCDs) require: “Use the code which does meet LCD guidelines as the first-listed code and add G89.- as a secondary code,” Miller said.