Part B Insider (Multispecialty) Coding Alert

New guidelines clarify fracture care coding

Confused about new postoperative and chronic pain codes? Help is here.

The Centers for Medicare & Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) have issued new ICD-9 coding guidelines, just in time to help you learn to use the new diagnosis codes that took effect Oct. 1. The guidelines are available at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf.

The new pain management codes include the following:

- 338.0--Central pain syndrome
- 338.18--Other acute postoperative pain
- 338.19--Other acute pain
- 338.21--Chronic pain due to trauma
- 338.28--Other chronic postoperative pain
- 338.29--Other chronic pain 
- 338.3--Neoplasm-related pain (acute) (chronic)
- 338.4--Chronic pain syndrome.

Learn the rules: The guidelines say you should only assign a code from 338.1x or 338.2x if the doctor hasn't yet made a definitive diagnosis. If the doctor already has made a definitive diagnosis, then you should list that first and the pain diagnosis second, if at all. You should use the codes from 338.1x and 338.2x when the main purpose of the visit is pain management, they add.

A specific diagnosis requires a more specific code than one from 338.2x, such as reflex sympathetic dystrophy, says Kelly Dennis with Perfect Office Solutions in Leesburg FL. Use 338.3 for cancer-associated pain.

Also, you should only use 338.4 if your patient actually has -chronic pain syndrome,- the guidelines say. -This condition is different than the term -chronic pain,- and therefore you should only use this code when the provider has specifically documented this condition,- they say.

The descriptor for 338.4 specifies pain should be -associated with significant psychosocial dysfunction,- which may limit use of the code, Dennis says.

Fracture care: Separately, the new guidelines specify that you should report pathologic fractures using subcategory 733.1 when the patient is receiving -active treatment.- Once the patient has completed active treatment, use aftercare codes in subcategories V54.0, V54.2, V54.8 or V54.9. Similarly, use 800-829 for active treatment of traumatic fractures and aftercare codes for aftercare.

Use the -appropriate complication codes- to report fracture complications.

When a patient develops systemic inflammatory response syndrome (SIRS) as a result of -certain non-infectious disease processes,- and no infection results, report the code for the underlying condition, such as an injury. Then, report 995.93 or 995.94 for the SIRS, the guidelines state. If the doctor documents an acute organ dysfunction, record the appropriate organ dysfunction codes along with 995.94.