Pain Management Coding Alert

Denials likely to head your way without detailed Dx.

If a patient has pain in any limb — arm or leg — there is a single diagnosis coding family for just about every iteration of the condition.

The code set is M79.6- (Pain in limb, hand, foot, fingers and toes), but don’t be fooled by the convenience of all these limb pain codes in the same ICD-10 section. If you were to submit a claim with the M79.6- code as a diagnosis, “insurance may deny,” explains Manny Oliverez, CPC, CEO of Capture Billing & Consulting, Inc., in South Riding, Virginia. “This code is appropriate, but unspecified.”

Also, if the pain is localized to a section of a limb, you might have to get even deeper into detail for the diagnosis coding. No worries, though. we’re going to show you how to drill down to the most accurate diagnosis code possible for your limb pain claim, with advice from experts that have plenty of diagnosis coding experience.

Remember 5th and 6th Characters

First, you’ll need to make sure you have a complete limb pain diagnosis code; in addition to the fifth character code choice to indicate anatomy of limb pain, “M79.6- requires a sixth character, so you would need to get more specific by assigning the location of the pain in the limb,” says Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA, senior manager of healthcare consulting for Seim Johnson in Omaha, Nebraska. For example, you’d report one of the following complete codes for limb pain, depending on the situation:

• M79.601 — Pain in right arm
• M79.602 — Pain in left arm
• M79.603 — Pain in arm, unspecified
• M79.604 — Pain in right leg
• M79.605 — Pain in left leg
• M79.606 — Pain in leg, unspecified
• M79.609 — Pain in unspecified limb.

Example: A new patient reports to the PM specialist complaining of pain in his entire left leg; he says the pain has been nearly constant for a week, and is aggravated by walking and standing. Currently, he rates his pain as a 7 on a scale of 10. Encounter notes indicate that the PM specialist performed an expanded problem-focused history and an expanded problem-focused examination, along with low-level medical decision making (MDM). Final diagnosis is pain in the left leg. The PM specialist instructs the patient on care, and tells him to follow up in two weeks if the pain hasn’t subsided.

On this claim, you’d append M79.605 to 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making …) to represent the patient’s limb pain.

Get More Specific, if Possible

The above diagnosis codes aren’t the entirety of the limb pain coding picture, however. If the patient gets more specific about the pain — reporting pain only in the lower leg, upper arm, forearm, etc. — you’ll choose a diagnosis from M79.62- (Pain in upper arm) through M79.67- (Pain in foot and toes), Oliverez confirms.

“The codes in this range also requires a 6th character for additional specificity,” reminds Swanson.

Consider this clinical scenario from Swanson:

A 12-year-old male established presents to the clinic with a chief complaint of right forearm pain for the past three days. The provider examines the patient, and notes that the right forearm is slightly red and mildly swollen. The patient has full range of motion of his right wrist, hand, and fingers, as well as in his shoulder. The provider notes a small amount of bruising on the mid-forearm. She makes the decision to monitor the patient, and doesn’t order an X-ray. Notes indicate that the provider performed an expanded problem-focused history and exam, along with straightforward MDM.

For this patient encounter, you’d append M79.631 (Pain in right forearm) to 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) to represent the patient’s forearm pain.

E/M Isn’t Only Service for Limb Pain

While the above examples illustrated encounters in which the provider performs an evaluation and management (E/M) service for a patient with limb pain, there are other services that a patient with limb pain might require.

“Generally, the evaluation of limb pain with a healthcare practitioner includes a history and physical exam to determine the patient’s potential cause of the pain,” explains Swanson. Typically, you’ll code these exams with the appropriate E/M code.

If a patient has limb pain, your provider could do more than perform an E/M service — and if you miss the non-E/M services you could have coded for, your claim will suffer.

Be on the lookout: The provider might elect to perform one of the following tests or procedures for patients with limb pain:

• Blood tests (to detect an infection, gout, etc.);
• X-rays;
• ultrasound (US);
• arteriogram;
• computed tomography (CT) scan;
• magnetic resonance imaging (MRI);
• nerve conduction studies (NCS);
• joint aspiration; or
• compartment studies.

Caveat: This is not a complete list of the types of services that your provider might perform for limb pain patients. These are merely examples; you should always code every encounter as per the provider’s notes, and you might see one of these services listed for a patient with limb pain.

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