Eli's Rehab Report

Report 338.4 only when significant psychological dysfunction is documented

Confused about new postoperative and chronic pain codes? Help is on the way. 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 online at www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf.

First, if you're not aware of the new pain management codes, take note of them:

• 338.0 -- Central pain syndrome

• 338.1x -- Acute pain

• 338.11 -- Acute pain due to trauma

• 338.12 -- Acute post-thoracotomy pain

• 338.18 -- Other acute postoperative pain

• 338.19 -- Other acute pain

• 338.2x -- Chronic pain

• 338.21 -- Chronic pain due to trauma

• 338.22 -- Chronic post-thoracotomy pain

• 338.28 -- Other chronic postoperative pain

• 338.29 -- Other chronic pain

• 338.3 -- Neoplasm-related pain (acute) (chronic)

• 338.4 -- Chronic pain syndrome.

Code to the Reason of the Visit

The good news is, you have a lot more options to work with now, but you must be careful to remember why the patient is visiting your facility so that you can code properly. For instance, given your options above, the guidelines say that if the patient's pain is not specified as "acute" or "chronic," you may not assign codes with "acute" or "chronic" in the descriptors.

Exception: In the case of post-thoracotomy pain, postoperative pain or neoplasm-related pain, you may assign codes from the 338.xx category.

The guidelines also note that you may not assign a code from 338.1x or 338.2x if the doctor has already made a definitive diagnosis -- unless the reason for the therapist's encounter is pain control. How it works: If the doctor has already made a definitive diagnosis, and your therapy clinic is providing pain management treatments, you should list the pain code first and the underlying condition second.

Remember, 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, Fla.

Helpful: You may also use 338.x codes with codes that identify the site of pain, guidelines say. For example, if the therapist's encounter is for control of acute neck pain due to trauma, report 338.11 first, followed by 723.1 (Cervicalgia) to identify the pain site. But if the encounter is for something other than pain control, and the patient does not have a definitive diagnosis, assign the code for the specific site of pain first, and report the appropriate 338 code second, guidelines say.

As for the code for cancer-associated pain (338.3), you will follow the same logic to order it correctly as with the 338.1x and 338.2x codes. List 338.3 first when the reason for the therapist's encounter is pain management, and report the underlying neoplasm as an additional diagnosis. On the other hand, if the reason for the visit is to manage the neoplasm itself, and the therapist happens to document pain associated with the neoplasm, you will code the neoplasm first and then 338.3 second as an additional diagnosis.
 
Note: The ICD-9 guidelines say to code 338.3 "regardless of whether the pain is acute or chronic."

Watch for Alternative Codes

Be sure you're aware of other coding options that may be more appropriate. For instance, if a patient has postoperative pain associated with a device left in the body, you should turn to the "Injury and Poisoning" codes, the guidelines say. They also note that you should not code "routine or expected postoperative pain immediately after surgery."

Another trap to watch for is that you should use 338.4 only when your patient actually has chronic pain syndrome. "This condition is different than the term 'chronic pain,' and therefore this code should only be used when the provider has specifically documented this condition," the guidelines say.

Tip: The descriptor for 338.4 specifies that pain should be "associated with significant psychosocial dysfunction," which may limit the code's use, Dennis says.

Pay Attention to Your Payer

Just because these new codes are out doesn't mean that you'll have smooth reimbursement sailing right away. "I have a feeling that payers may be slow in accepting these new pain codes as allowable codes to justify therapy treatment," says Ann Lambert Kremer, OTR/L, MHSA, CPC, of Beacon Rehab Solutions in Portland, Maine. With this in mind, make sure you revisit your local coverage determinations and make sure the codes are included, she says.