Health Information Management

Stay on top of post-op pain coding

HIM-HIPAA Insider, March 13, 2012

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ICD-9 guidelines indicate that coders should not report routine or expected postoperative pain that occurs immediately after surgery. Differentiating between postoperative pain and pain that occurs ­during the postoperative period is important, says Kathy DeVault, RHIA, CCS, CCS-P, manager of professional practice resources at AHIMA in Chicago. "Documentation is really the key," she says.

Ask the following questions to determine whether pain is normal or whether it warrants assignment of a postoperative pain code:
  • Is the patient receiving large amounts of IV pain medication three to four days (or more) after the surgery?
  • Did the patient undergo any tests after surgery to investigate the pain?
  • Does documentation state that nurses and other providers are monitoring the postoperative wound because of what appears to be an unusual amount of pain?
Postoperative pain often requires a query, says DeVault. Coders should always refer to clinical indicators in the chart, and they should consider attaching a portion of the ICD-9 guidelines related to pain coding for reference. Also consider educating neurosurgeons and orthopedic surgeons about postoperative pain coding and documentation requirements.
 
Editor’s note: Read the entire article in the February issue of Briefings on Coding Compliance Strategies.



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