Question ICD 10 coding for Rectal pain?

chankim

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Hello, I work at outpatient hospital at cedars for pain injections.

I have a ganglion impar block and the Dx in the notes is - rectal pain.

What would be the proper ICD code for rectal pain?
 

kpeterson15

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Since the index brings you to the K code, I would use the K code. The G89 code has specific guidelines to follow to be able to use it, if this case meets that criteria, you could use it as an additional code. :)
 

chankim

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Got it thank you so much!

So on the actual notes diagnosis it has the following:

- rectal pain
- painful spasms of the anus

Would K62.89 still be the primary code? And does the "G" pain code have to be used in addition?
 

kpeterson15

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With everything you just gave me, I would not use a G89 code because the rectal pain it is not specified as acute, chronic, neoplasm-related, or postprocedural. As for the principal, whatever condition the block was for I would code that as principal since that is what brought the patient in and had them get the injection.
 

chankim

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With everything you just gave me, I would not use a G89 code because the rectal pain it is not specified as acute, chronic, neoplasm-related, or postprocedural. As for the principal, whatever condition the block was for I would code that as principal since that is what brought the patient in and had them get the injection.
On the HPI section of the notes it says the patient suffers from chronic rectal pain - so not sure if that info will allow me to use G89?
 

kpeterson15

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I personally would not code the G89 code just because it does not say anything about chronic in the final diagnosis assessment. I am a new coder, so maybe a veteran coder would be able to assist more if you could use the G89 based on the HPI. I was always taught, if you can back up your codes if they get audited you can code it. If you cannot, do not code it.

Here a forum that discusses a little bit on the use of HPI for coding diagnoses.
 

chankim

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thanks that is helpful to know.

I'm also thinking if it would be appropriate in this case to try anal spasms for the Dx.

K59.4 Anal Spasm is also an option
 

kpeterson15

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thanks that is helpful to know.

I'm also thinking if it would be appropriate in this case to try anal spasms for the Dx.

K59.4 Anal Spasm is also an option
Yea I would code rectal pain and anal spasm as long as there is no excludes 1 for either of those codes and they can be coded together. :)
 
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