Check Your Pain Coding Know-how

Put your diagnosis coding skills to the test with this patient encounter.

CC: Hip pain

HPI: The patient is a 38-year-old woman presenting to our clinic for evaluation of hip pain, right greater than left, of more than two years duration. The patient states that it began with right hip pain, getting steadily worse over the last two years, during which she developed pain in the left hip. The pain is located laterally as well as anteriorly around the groin. She states that the pain is present during activities such as walking; she reports some painful popping and clicking in the right hip. This is the first time she’s sought medical attention for this.

ROS: As per HPI. Patient reports occasional indigestion and nausea; otherwise, all other systems are negative.

PMH/PSH: No significant medical problems; no prior surgeries.

MEDS: Reviewed with the patient, she takes a multivitamin and OTC pain meds PRN.

ALLERGIES: NKDA.

SOCIAL Hx: The patient is married. She is employed as an office manager. She drinks socially, denies smoking and illicit drug use. She exercises a couple of times a month, mainly walking and low impact aerobics.

PHYSICAL EXAM: Vitals: BP 129/84; HR 81, RR 17, pulse ox 98%. Height: 5’ 2”; weight 155 pounds; NAD.

CARDIO: RRR; no MRG; LUNGS: CTAB; no respiratory distress.

PELVIS/EXTREMITIES: The patient ambulates independently without an assist device; normal stance and gait. Inspection of the hips reveals normal contour and appearance and good symmetry. The patient is able to do an active straight leg raise against gravity and against resistance bilaterally. She has no significant trochanteric tenderness. She does, however, have some tenderness in the groin bilaterally. There is no crepitus present with passive or active range of motion of the hips. Grossly neurologically intact in the bilateral lower extremities.

DIAGNOSTIC STUDIES: X-rays performed today in the clinic include an AP view of the pelvis and a frog-leg lateral of the right hip. There are no acute findings, no fractures or dislocations. There are minimal degenerative changes noted in the joints. There is, however, the suggestion of an osteoma on the superior femoral neck, which could be causing femoroacetabular impingement.

ASSESSMENT: Chronic bilateral hip pain, right worse than left, possibly suggesting femoroacetabular impingement based on X-rays. Her clinical picture is also consistent with a possible labral tear.

PLAN: After discussing possible diagnoses with the patient, I have recommended that we get MRI arthrograms of the bilateral hips to evaluate the anatomy, concentrating on the labrum in the right hip in particular. She will get that done as soon as possible. In the meantime, she is asked to moderate her activities. She will follow up as soon as the MRIs are performed.

Code the Diagnosis

ICD-10-CM codes:

M25.551 Pain in right hip

M25.552 Pain in left hip

G89.29 Other chronic pain

Rationale: The patient presents for evaluation of chronic bilateral hip pain. The physician lists two possible etiologies in her assessment: femoroacetabular impingement, labral tear. As these are not confirmed, the hip pain is coded. There is no bilateral code for hip pain in ICD-10-CM; therefore, two codes are necessary to indicate both hips are affected. Note, the fact that the hip pain is chronic is not addressed in the hip pain codes.

In this case, since the site-specific codes do not address the temporal parameter of the pain (chronic), codes in category G89 Pain, not elsewhere classified can be used to further classify the patient’s pain. According to Guideline I.C.6.b.1.b.i, “Codes from category G89 may be used in conjunction with codes that identify the site of pain … if the category G89 code provides additional information,” such as whether the pain is acute or chronic.

Sequencing of these codes will depend on the reason for the encounter. Guideline I.C.6.1.b.ii states that if the patient is presenting for pain control or pain management, then the G89 code should be sequenced first. If the encounter is for any other reason and a related definitive diagnosis has not been established by the provider, the site-specific pain code should be sequenced first. In this case, the patient presents for evaluation, not for pain management, so the hip pain codes are sequenced first.

Resources:

2021 ICD-10-CM code book

2021 ICD-10-CM Official Guidelines for Coding and Reporting

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Stacy Chaplain

Stacy Chaplain, MD, CPC, is a development editor at AAPC. She has worked in medicine for more than 23 years, with an emphasis on education, writing, and editing since 2015. Chaplain received her Bachelor of Arts in biology from the University of Texas at Austin and her doctorate in medicine from the University of Texas Medical Branch in Galveston. She is a member of the Beaverton, Ore., local chapter.

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