Pain Management Coding Alert

Best practice: Include a “causation statement” with your claim.

When you’re choosing a diagnosis code for patients with pain related to psychological disorders, ordering the ICD-10 codes properly is vital to correct coding.

“It’s a chicken-and-egg situation,” says Asokumar Buvanendran, MD, William Gottschalk Endowed Chair of Anesthesiology, Vice Chair Research & Director of Orthopedic Anesthesia, and professor of anesthesiology at Rush University Medical Center in Chicago.

“You need to know which condition came first,” says Buvanendran who is also the president-elect for the American Society of Regional Anesthesia and Pain Medicine (ASRA).

So when you look at assigning diagnosis codes for these patients, be sure to ask yourself: Did the pain cause the psychological issue, or did the psychological disorder cause the pain? Only then can you code correctly.

Check out this advice on identifying all manner of pain related to psychological conditions.

Look to F45.4-, Note Excludes1 Designation

When you’re reporting pain related to psychological factors, you’ll be looking at the F45.4- (Pain disorders related to psychological factors) diagnosis code set, confirmed Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO, owner of MJH Consulting in Denver, Co. during the session “ICD-10 Coding for Pain Management,” at The Coding Institute’s CodingCon in December 2015.

Watch out: ICD-10 placed an Excludes1 note under the F45.4- descriptor for pain not otherwise specified (NOS). The Excludes1 note under F45.4- is R52 (Pain, unspecified).

If you have an F45.4x claim on your hands, you’ll have to choose from F45.41 (Pain disorder exclusively related to psychological factors) and F45.42 (Pain disorder with related psychological factors) to complete the diagnosis.

The basics: If the patient has pain that is exclusively related to a psychological (somatoform pain) disorder, you’ll only report F45.41. You don’t need to include any additional ICD-10 codes for these patients.

On the other hand, if the patient has a pain disorder that leads to a psychological issue, you’ll report F45.42.

You should use F45.42 with a code from the G89- (Pain, not elsewhere classified) ICD-10 category, “if there is documentation of a psychological component for a patient with acute or chronic pain,” Hammer advised.

Check out these quick encounter examples to help illustrate proper use of these ICD-10 codes:

Encounter 1: F45.41 Diagnosis

A new patient with an established diagnosis of recurrent, severe major depressive disorder without psychotic features reports to the practice complaining of deep depression for the last three weeks along with a “constant aching” in her body. She says the pain is so great she has had to miss work several days, and often she cannot even get out of bed. She reports that the pain started two or three days after her current depression. The physician diagnoses pain caused by the patient’s depression and prescribes medication. Notes indicate a level-three E/M service.

On this claim, you’d report 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity…) for the E/M. Remember to append F45.41 and F33.2 (Major depressive disorder, recurrent severe without psychotic features) to 99203 to represent the patient’s symptoms.

While depression is frequently the culprit when a patient suffers chronic pain, there are other psychological issues that could trigger pain, including anxiety, somatization disorders, drug dependence, and personality disorders. If a patient reporting for pain treatment has one of these conditions, keep F45.41 at the ready.

Encounter 2: F45.42 Diagnosis

An established patient with a diagnosis of chronic pain stemming from an automobile accident reports to the practice for a routine follow-up. The patient’s pain, which started two years prior, has left him unable to work, exercise, or even “sit up straight sometimes.” For the last 10 days, the patient reports feeling like he’s never going to get better. Though he claims no suicidal ideations, the patient says he has wondered if he’d be better off dead a few times, because “at least the pain would stop.” The physician performs a level-five E/M service, during which she diagnoses single-episode, moderate major depressive disorder. She prescribes medication and refers the patient to a psychologist to assist in treating his depression.

In this instance, you’d report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity…) for the E/M, with F45.42, G89.21 (Chronic pain due to trauma), and F32.1 (Major depressive disorder, single episode, moderate) appended to represent the patient’s condition.

This type of depression can often occur when a highly functional person is rendered inactive. “A Type A personality that cannot function obviously could have moderate depression,” explains Buvanendran.

A F45.42 diagnosis also frequently means a referral to a psychologist/psychiatrist. “Someone suddenly stuck with chronic pain often needs [psychological] help to get back on track,” Buvanendran says.

Remember to Document Psychological Components

When you are coding claims for pain related to psychological factors, “documentation of any psychological component to a patient with acute or chronic pain is essential for code assignment of these conditions,” Hammer said.

For example, consider the previous example of a patient with chronic back pain suffering from depression. Along with the claim, you should include a “causation” or “relatedness” statement. For example, “The patient’s new depression is secondary or resulting from chronic pain condition.”