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pain diagnosis question

  1. #1
    Default pain diagnosis question
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    Hi, I am auditing a pain specialist. The patient came in with a history of uncontrollable postoperative pain (not current). My provider is consulted because she has another scheduled oral surgery coming up. My provider is putting a plan together to treat the (future) postoperative pain.

    My question is what diagnosis should the visit been billed with? He had used 784.0--but never mentioned that she was experienceing current pain.
    His assessment was:

    1. Extensive dental and oral surgical work planned
    2. poor postoperative pain control

    Obviously she doesn't have 784.0. Should the diagnosis be V65.49? or ok to use the 338.13 diagnosis?

    Any input would be appreciated.
    Thanks,
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

  2. #2
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    Pain(s) (see also Painful) 780.96
    face, facial 784.0
    atypical 350.2
    nerve 351.8
    head (see also Headache) 784.0
    784 784.1

    These are additional index entries from www.icd9data.com

    It looks like head or facial pain could fall under 784.0. This was probally done before October 1st, 2010. The new jaw pain code might of worked.

  3. #3
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    If you look under the guidelines for the 338 codes and specifically postoperative pain you will see where it states first that these codes are to be used when the nature of the visit is for pain controll. In addition for postoperative pain the physician need only state that the visit is for post op pain and we default that to acute post op pain. So there is your code. IMO

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
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    Thank you Debra, I did read that and that's why I believe I considered the 338 series. I appreciate your input.
    Melissa Tescher, CPC, CPMA, CEMC Compliance and Coding Specialist
    Willamette Valley Professional Services member National Advisory Board 2013-2015

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