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Resolved Diagnosis Code documentation

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DawnO_65360

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Can anyone clarify this:

Physician has documented chronic pain in HPI, but does not list it in the diagnosis list on MR.
As a coder are we allowed to code this and add it to the claim form or does it specifically need to be documented by the physician.
 
You can code it if it was treated or if it can affect care but you do need documentation to support the code chosen.

One of the big mistakes in pain management billing and coding is to bill a procedure based only upon a summary. According to Medicare, you are only permitted to bill for any procedures that have been documented in the body of a report. This means that coders must look beyond the summary that’s at the beginning of the report for coding purposes.

Per ICD-10-CM Official Guidelines (section I.C.6), you “may use codes from category G89 with codes that identify the site of pain (including codes from chapter 18) if the category G89 code provides additional information. For example, if the code describes the site of the pain, but does not fully describe whether the pain is acute or chronic, then both codes should be assigned.”
The Guidelines further tells us, “If the pain is not specified as acute or chronic, post-thoracotomy, postprocedural, or neoplasm-related, do not assign codes from category G89.”

Types of Pain Codes

You can find pain codes in three different places in the ICD-10-CM manual:

  • Pain that points to a disorder of a specific body system is classified in the body system chapters. For example, low back pain is classified in the Musculoskeletal chapter (M54.5) and testicular pain is classified in the Genitourinary System chapter (N50.8).
  • Pain that does not point to a specific body system is classified in the Symptoms and Signs chapter. For example, abdominal pain is classified to category R10.
  • Certain specific types of pain are classified to category G89 (Pain, not elsewhere classified) in the Nervous System chapter


b. Pain - Category G89
1) General coding information
ICD-10-CM Official Guidelines for Coding and Reporting
FY 2021
Page 45 of 126
Codes in category G89, Pain, not elsewhere classified, may be
used in conjunction with codes from other categories and
chapters to provide more detail about acute or chronic pain and
neoplasm-related pain, unless otherwise indicated below.
If the pain is not specified as acute or chronic, postthoracotomy, postprocedural, or neoplasm-related, do not assign
codes from category G89.
A code from category G89 should not be assigned if the
underlying (definitive) diagnosis is known, unless the reason for
the encounter is pain control/ management and not management
of the underlying condition.
When an admission or encounter is for a procedure aimed at
treating the underlying condition (e.g., spinal fusion,
kyphoplasty), a code for the underlying condition (e.g.,
vertebral fracture, spinal stenosis) should be assigned as the
principal diagnosis. No code from category G89 should be
assigned.
(a) Category G89 Codes as Principal or First-Listed
Diagnosis
Category G89 codes are acceptable as principal
diagnosis or the first-listed code:
• When pain control or pain management is the reason
for the admission/encounter (e.g., a patient with
displaced intervertebral disc, nerve impingement and
severe back pain presents for injection of steroid into
the spinal canal). The underlying cause of the pain
should be reported as an additional diagnosis, if
known.
• When a patient is admitted for the insertion of a
neurostimulator for pain control, assign the
appropriate pain code as the principal or first-listed
diagnosis. When an admission or encounter is for a
procedure aimed at treating the underlying condition
and a neurostimulator is inserted for pain control
during the same admission/encounter, a code for the
underlying condition should be assigned as the
principal diagnosis and the appropriate pain code
should be assigned as a secondary diagnosis.
(b) Use of Category G89 Codes in Conjunction with Site
Specific Pain Codes
ICD-10-CM Official Guidelines for Coding and Reporting
FY 2021
Page 46 of 126
(i) Assigning Category
G89 and Site-Specific
Pain Codes
Codes from category G89 may be used in
conjunction with codes that identify the site of
pain (including codes from chapter 18) if the
category G89 code provides additional
information. For example, if the code describes
the site of the pain, but does not fully describe
whether the pain is acute or chronic, then both
codes should be assigned.
(ii) Sequencing of
Category G89 Codes
with Site-Specific Pain
Codes
The sequencing of category G89 codes with sitespecific pain codes (including chapter 18 codes),
is dependent on the circumstances of the
encounter/admission as follows:
• If the encounter is for pain control or pain
management, assign the code from
category G89 followed by the code
identifying the specific site of pain (e.g.,
encounter for pain management for acute
neck pain from trauma is assigned code
G89.11, Acute pain due to trauma,
followed by code M54.2, Cervicalgia, to
identify the site of pain).
• If the encounter is for any other reason
except pain control or pain management,
and a related definitive diagnosis has not
been established (confirmed) by the
provider, assign the code for the specific
site of pain first, followed by the
appropriate code from category G89.
2) Pain due to devices, implants and grafts
See Section I.C.19. Pain due to medical devices
3) Postoperative Pain
The provider’s documentation should be used to guide
the coding of postoperative pain, as well as Section III.
Reporting Additional Diagnoses and Section IV.
ICD-10-CM Official Guidelines for Coding and Reporting
FY 2021
Page 47 of 126
Diagnostic Coding and Reporting in the Outpatient
Setting.
The default for post-thoracotomy and other
postoperative pain not specified as acute or chronic is
the code for the acute form.
Routine or expected postoperative pain immediately
after surgery should not be coded.
(a) Postoperative pain not associated with specific
postoperative complication
Postoperative pain not associated with a specific
postoperative complication is assigned to the appropriate
postoperative pain code in category G89.
(b) Postoperative pain associated with specific
postoperative complication
Postoperative pain associated with a specific
postoperative complication (such as painful wire
sutures) is assigned to the appropriate code(s) found in
Chapter 19, Injury, poisoning, and certain other
consequences of external causes. If appropriate, use
additional code(s) from category G89 to identify acute
or chronic pain (G89.18 or G89.28).
4) Chronic pain
Chronic pain is classified to subcategory G89.2. There is
no time frame defining when pain becomes chronic pain.
The provider’s documentation should be used to guide
use of these codes.
5) Neoplasm Related Pain
Code G89.3 is assigned to pain documented as being
related, associated or due to cancer, primary or
secondary malignancy, or tumor. This code is assigned
regardless of whether the pain is acute or chronic.
This code may be assigned as the principal or first-listed
code when the stated reason for the admission/encounter
ICD-10-CM Official Guidelines for Coding and Reporting
FY 2021
Page 48 of 126
is documented as pain control/pain management. The
underlying neoplasm should be reported as an additional
diagnosis.
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.
See Section I.C.2 for instructions on the sequencing of
neoplasms for all other stated reasons for the
admission/encounter (except for pain control/pain
management).
6) Chronic pain syndrome
Central pain syndrome (G89.0) and chronic pain
syndrome (G89.4) are different than the term “chronic
pain,” and therefore codes should only be used when the
provider has specifically documented this condition.
See Section I.C.5. Pain disorders related to
psychological factors
 
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