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Coding 101:

Take the Pain Out of Pain Coding With These Tips

Published on Sun Jan 16, 2011 Print Friendly and PDF PDF

Not every patient with severe pain needs a pain diagnosis code.

Your patient's OASIS assessment indicates she is experiencing severe pain. Should you list a 338.x (Pain) diagnosis code in M1020/M1022? The answer depends on each patient's unique situation. Read on for expert tips to improve your pain coding accuracy.

Know These Crucial Pain Items

The OASIS includes two pain items: M1240 -- Has this patient had a formal Pain Assessment ... and M1242 -- Frequency of Pain Interfering with patient's activity or movement.

OASIS item M1240 asks if the patient had a formal pain assessment using a standardized pain assessment tool and if so, was severe pain identified or not, says Sparkle Sparks, MPT, HCS-D, COS-C, with Redmond, WA-based OASIS Answers. OASIS item M1242 wants to know the frequency of pain interfering with a patient's activity or movement, she says.

The 338.x (Pain) codes describe many different kinds of pain. But reporting one of these codes isn't appropriate for every patient who is experiencing pain.

Is the Pain Acute or Chronic?

Before you can list one of the 338.x codes for a patient experiencing pain, you'll need to have the medical documentation to back the code up. Category 338.x codes can be used to provide more detail about acute, chronic, or neoplasm-related pain. But in order to list a 338.x code for acute or chronic pain, you must have medical documentation that specifies the pain as acute or chronic, Sparks says.

How do you know when pain becomes chronic? "There is no time frame defining when pain becomes chronic," Sparks says. You must rely on the physician documentation to make that determination.

Exception: In the case of post-thoracotomy pain, postoperative pain, or neoplasm-related pain, you may assign an appropriate code from the 338.x category without documentation indicating whether the pain is acute or chronic. Acute pain is the default if the physician hasn't documented the chronic nature of the pain.

List Pain First for Pain Management

Pain is a symptom, and it's better to list a definitive diagnosis as your primary diagnosis, Sparks says. But that's not always possible.

You'll list a 338.x code first when pain control or management is the reason for the admission, Sparks says. In that case, list the 338.x code first and include additional codes to indicate the underlying cause for the pain.

Tip: Pain is not considered integral to cancer. Neoplasm related pain may be assigned as the principal code when the stated reason for admission is documented as pain control/management, regardless whether the neoplasm is benign or malignant, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, HCS-O, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas. The underlying neoplasm should be reported as an additional diagnosis. When the reason for the admission is management of the neoplasm and the pain associated is also documented, code 338.3 may be assigned as an additional diagnosis, she says.

Coding example: Your patient has a history of uterine cancer for which she has received successful treatment. The current referral is for pain management of chronic pelvic pain related to the neoplasm that is affecting her ability to complete activities of daily living (ADLs) and instrumental activities of daily living (IADLs).

For this patient, list the following codes, suggests Judy Adams, RN, BSN, HCS-D, COS-C with Adams Home Care Consulting in Chapel Hill, N.C.:

  • M1020a: 338.3 (Neoplasm related pain [acute] [chronic]); and
  • M1022b: V10.42 (Personal history of malignant neoplasm; genital organs; other parts of uterus).

Helpful: You may also use 338.x codes with codes that identify the site of pain, the guidelines say. For example, if your therapist is working with the patient to provide control of acute neck pain due to trauma, code 338.11 first, followed by 723.1 (Cervicalgia) to identify the pain site.

Sequence 338 Second For More Detail

The 338.x codes can also be listed as secondary codes in three instances: when you are addressing pain assessment, when pain impacts the plan of care associated with a thoracotomy or neoplasm, or with codes that identify the site of pain when the pain code provides more detail about the pain, Adams notes.

Sequencing tip: 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.x code second, guidelines say.

Coding example: If your focus is on managing a patient's cancer, and the clinician happens to document pain associated with the neoplasm, you will code the neoplasm first and then 338.3 second as an additional diagnosis.

Take note: The ICD-9 guidelines say to report code 338.3 "regardless of whether the pain is described as

acute or chronic." However, for post-thoracotomy, post-operative or post trauma pain, acute pain is the default code and chronic pain can only be assigned when the physician specifically documents the presence of chronic pain, Adams points out.

Don't Code for Routine Pain

When coding for postoperative pain, it's not appropriate to list a 338.x code, Sparks says. The guidelines also note that you should not code "routine or expected postoperative pain immediately after surgery." Only list a 338.x code if the pain is causing quality of life issues requiring you to care plan around it, she says.

Remember: The 338.x codes aren't appropriate when pain is integral to your patient's diagnosed condition. If the pain is a symptom of the patient's condition, code for the condition instead.

Coding example: Your patient has chronic venous insufficiency and a stasis ulcer of the ankle. She reports her pain as burning, tingling and shooting and says that it is present continuously. She rates the pain as a 10 on a scale of 1-10. For this patient, list the following codes, Adams suggests:

  • M1020a: 459.81 (Venous [peripheral] insufficiency, unspecified); and
  • M1022a: 707.13 (Ulcer of ankle).

Don't list a 338.x pain code for this patient because the pain is a symptom of chronic venous insufficiency, Adams explains.

Another trap: Use 338.4 (Chronic pain syndrome) only when your patient actually has chronic pain syndrome. This condition is different from "chronic pain," so this code should be used only when the provider has specifically documented this condition, the guidelines say.

In fact, the physician or medical record must specifically state the presence of either of the two pain syndromes: 338.0 (Central pain syndrome) or 338.4 (Chronic pain syndrome) in order for you to report these diagnoses, Adams says.

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