Pain management coding: does injury codes apply to pain?

Here's pain management coding scenario to help your understanding: When can you report an acute injury ICD-9 code rather than a chronic injury code? We treat patients for generalized pain (not necessarily a recent injury) and are not sure what to code.

Answer: When coding some conditions such as kidney disease (584.x and 585.x), you can many a time easily figure out when the patient's condition is chronic as the diagnosis codes differ based on the patient's lab results. However, coding for pain can be trickier.

Say for instance your patient presents with shoulder pain, which came on slowly; that she says she had for some time. You think about 840.4; however it's from ICD-9's ‘injury' chapter. In this instance, the patient did not have an injury – in its place she had nine months of pain. As such, you should avoid 840.4 and choose another code based on the rest of your physician's documentation. You'd most likely look for notes pertaining to the patient's signs and/or symptoms, such as 719.41 of your provider has not determined what is causing the patient's shoulder pain and hasn't given a definitive diagnosis. And once a definitive diagnosis has been reached, you no longer code the symptoms.

Here's why: Acute pain normally results from disease, surgery, inflammation or injury. The pain is immediate and normally of a short duration. By contrast, chronic pain typically persists beyond three to six months and can last from weeks to a lifetime. Chronic pain can originate with an initial trauma or injury; however continues beyond the time of normal healing. Many practices use the ‘three months or longer' guideline for coding chronic pain conditions versus acute problems. A definitive guideline hasn't been addressed by CMS, even though it has identified coverage of electrical stimulation for chronic wounds as longer than a month.

Pain management coding: Do injury codes apply to pain?

You could be using the wrong code if you are not aware what differentiates an acute condition from a chronic one, or how many diagnosis codes you can report. Here's a common question to help your pain management coding (ICD-9).

When can you report an acute injury ICD-9 code rather than a chronic injury code? We tend to patients for generalized pain (not necessarily a recent injury) and are not sure what to code.

Answer: While coding some conditions like kidney disease (584.x and 585.x), often you can easily figure out when the patient's condition is chronic since the diagnosis codes differ based on the patient's lab results. However, coding for pain can be trickier.

Here's an instance: Think that your patient presents with shoulder pain, which came on slowly, that she says she has had for the last nine months. You can think about 840.4; however it is from ICD-9's "injury" chapter. In this instance, the patient did not have an injury; in its place she had nine months of pain. As such, you should stay away from 840.4 and choose another code based on the rest of your physician's documentation. Most likely you'd look for notes pertaining to the patient's signs and/or symptoms, such as 719.41 if your provider hasn't determined what is causing the patient's shoulder pain and hasn't given a definitive diagnosis. Once a definitive diagnosis has been reached, you no longer need to code the symptoms.

Here's why: Generally acute pain results from disease, surgery, inflammation, or injury. The pain happens to be immediate and normally short-lived. By comparison, chronic pain can originate with an initial trauma or injury however continues beyond the time for normal healing. Many practices use the ‘three months or longer' guideline for coding chronic pain conditions in comparison to acute problems. "A definitive guideline has not been addressed by Centers for Medicare & Medicaid; but it has identified coverage of electrical stimulation for chronic wounds as ‘longer than one month'.

Bottom line: You should leave the determination of acute versus chronic to the physician. If an ICD-9 or CPT code compels you to differentiate between whether the patient's condition is acute or chronic, show both descriptors to the pain specialist and ask him to take a stance.

ICD-9 includes code family 338.xx for acute and chronic pain diagnoses. However, as per Section 1.B.6 of the ICD-9 Guidelines, do not assign codes from category 338.xx if you don't have an "acute" or "chronic" distinction. The sole exception to this guideline lie with post-thoracotomy pain, postoperative pain, neoplasm related pain, or central pain syndrome. If acute or chronic is not specified, you need to look elsewhere for the code.

00918 is primary anesthesia code for procedures 52352-52355

However don't make it your automatic choice.

While coding for your anesthesia practice, you may find yourself in various tight situations such as this: Say for instance you may find yourself asking: How should I code for anesthesia during a cystourethroscopy with lithotripsy for a diagnosis of kidney or ureteral stones?

Answer: Well, the anesthesia code crosswal lists   00918 (anesthesia for transurethral procedures [including urethrocystoscopy]; with fragmentation, manipulation and/or removal of ureteral calculus) as the primary anesthesia code for procedures 52352-52355 (Cystourethroscopy, with ureteroscopy and/or pyeloscopy …) however you should not make that your automatic choice.

Notes below each code from 52352-52355 state that you should report 00862 (Anesthesia for extraperitoneal procedures in lower abdomen, inclusive of urinary tract; renal procedures, including upper one-third of ureter, or donor nephrectomy) when lithotripsy involves the kidney or upper one-third of the ureter. Owing to this ‘upper one-third' distinction, you will need a copy of the operative report to code properly.

Many a medical coder gauge their condition by the stone's location. They submit 00910 (Anesthesia for transurethral procedures [including urethrocystoscopy]; not otherwise specified) for a bladder stone, 00918 for a ureter stone, and 00862 for a kidney stone.

For more on this and for other specialty-specific articles to assist your anesthesia coding, sign up for a good coding resource like TCI. Onboard such a site, you can have access to the anesthesia analyst that provides you with anesthesia codes, tools, and resources you need for successful coding. It also comes with an anesthesia code crosswalk to help you choose the proper anesthesia code for each CPT procedure code in the record. Basically, the anesthesia crosswalk is a listing of CPT procedure codes and their corresponding anesthesia codes.