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Know how pain justifies medical necessity

HIM Connection, February 7, 2012

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Generally speaking, coders are taught not to code signs and symptoms that are integral to a disease process. However, when patients are admitted for pain control or pain management, the pain should be coded separately and it should be reported as the principal diagnosis.

For example, a patient with metastatic breast cancer presents with intractable neoplasm-related pain. She is admitted and treated with IV pain medication specifically for the pain. In this case, coders must assign a neoplasm-related pain code as the principal diagnosis, says Kathy DeVault, RHIA, CCS, CCS-P, manager of professional practice resources at AHIMA in Chicago.

In addition to providing a more accurate clinical picture, reporting acute or chronic pain can help establish medical necessity for certain procedures, says Monica Lenahan, CCS, an AHIMA-certified ICD-10-CM/PCS trainer and coding education and compliance manager at Centura Health in Englewood, CO. She frequently sees denials for spinal cord stimulators when codes for chronic pain, in particular, are absent.

Some MACs require a chronic or acute pain code as a prerequisite for payment. For example, TrailBlazer Health Enterprises, LLC, the MAC for Jurisdiction 4, has a dual diagnosis requirement for implantable pain management devices. Claims must include the reason for the procedure (e.g., the chronic pain) sequenced as the principal diagnosis in addition to a secondary code for the condition that caused the pain, explains Lenahan. Reviewing your MAC's guidelines to ensure compliance in this area is important, she says.

Editor’s note: This tip has been adapted from an article which originally appeared in the February issue of Briefings on Coding Compliance Strategies.

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