Inpatient Facility Coding & Compliance Alert

Question: A patient receives pain control measures for acute neck pain following an injury. How should we code this using ICD-10-CM?

Texas Subscriber

Answer: If the patient receives pain control measures for acute neck pain following an injury, that is, the patient sees the provider specifically for the purpose of pain control measures, assign the G89 (Pain not elsewhere classified) code first, followed by the site specific code. In this instance, you can code G89.11 (Acute pain due to trauma) followed by M54.2 (Cervicalgia).

G89 can be used along with codes from other categories to share additional details about acute, chronic, or neoplasm related pain. However, remember that: 

• If the pain isn’t acute, chronic, post-thoracotomy, post-procedural, or neoplasm related, then you will NOT use a G89 code.

• If a definitive diagnosis has been established, do NOT use a G89 code, unless the encounter is for pain management and not the underlying condition. 

• Going further, you can use G89 as a principal diagnosis code if the patient presents with severe pain, and pain control is the primary intervention the physician thinks of.