Health Information Management

Simplify diagnostic, procedural pain management coding

JustCoding News: Outpatient, July 11, 2012

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Pain is an expected component of injuries, illnesses, and surgical procedures. Let's face it, breaking your leg hurts. In some instances, however, the patient's pain is unexpected or is worse than predicted. Sometimes, the pain can last well beyond the time it should have resolved.

For those cases, coders can report codes from the 338 series of ICD-9-CM codes when the physician provides adequate documentation. In ­addition, ­coders can report a CPT® code for separate pain ­management procedures, which include various types of injections.
Types of pain
Pain can be acute, chronic, or both. It can also be related to a neoplasm, originate from the spine, or be part of a pain syndrome.
Do not assign a code from the 338 category to report localized pain with an identified specific site, such as the back or leg, says Shelley C. Safian, PhD, CCS-P, CPC-H, CPC-I, AHIMA-approved ­ICD-10-CM/PCS trainer of Safian Communications Services in Orlando, Fla. However, if the physician documents that localized pain as acute or chronic, coders would report both code 338.x along with a code for localized pain.
Acute pain coding
Acute pain is very severe pain and includes the following ICD-9-CM codes:
  • 338.11, acute pain due to trauma. The ­physician must specifically document the pain as acute. In ­order to report this code, the physician must ­document that the patient's pain is not just regular, ­inclusive, expected pain, Safian says. "We are ­talking about ­situations where the patient comes back and tells the physician that the pain medications are not working and he or she is still in tremendous amounts of pain. Therefore, something extra must be done." In ICD-10-CM, coders will ­report G89.11.
  • 338.12, acute post-thoracotomy pain. For this code, the physician does not have to document the pain as acute, Safian says. The code description includes a parenthetical note stating "post-thoracotomy pain not otherwise specified (NOS)." If the physician documents unexpected pain after a thoracotomy, coders can report this code, she says. In ICD-10-CM, coders will use G89.12.
  • 338.18, other acute postoperative pain. This code ­includes postoperative pain NOS, so the physician does not have to document acute pain for the code to be assigned. In ICD-10-CM, coders will ­report G89.18.
  • 338.19, other acute pain. This code includes anything that does not fit into one of the previous codes, but excludes neoplasm-related acute pain.
Do not assign ICD-9-CM codes 338.1x and 338.2x (chronic pain) or ICD-10-CM code series G89.- if the physician documentation shows a confirmed diagnosis for the underlying condition, Safian says. For example, if the patient comes back to see the physician for a follow-up of a fracture and discusses pain as part of the follow-up, coders should not report code 338.11. The exception to this guidance is when a patient comes in specifically for pain management—for example, if a patient sees a physician to complain of uncontrollable pain. In this case, coders should report the appropriate code from the 338.1x or 338.2x series.
Chronic pain coding
Chronic pain is ongoing pain. It is not limited to any specific time frame, so the physician must specifically document that the pain is chronic, Safian says. The fifth digit for chronic pain codes follows the same pattern as acute pain codes. The ICD-9-CM codes for chronic pain include:
  • 338.21, chronic pain due to trauma. In ICD-10-CM, coders will report G89.21.
  • 338.22, chronic post-thoracotomy pain. In ­ICD-10-CM, coders will report G89.22.
  • 338.28, other chronic postoperative pain. In ­ICD-10-CM, coders will report G89.28.
  • 338.29, other chronic pain. In ICD-10-CM, coders will report G89.29.
Neoplasm-related pain
Pain documented as related, associated, or due to either a primary or secondary malignancy (tumor) is considered neoplasm-related pain. ICD-9-CM code 338.3 includes pain identified as acute, chronic, or both, Safian says.
Coders need to pay attention to the ­sequencing guidelines for code 338.3. When the encounter is for pain control, report 338.3 first, Safian says, followed by the code or codes for the neoplasm causing the pain. When the encounter is for treatment of the neoplasm and pain control is a secondary concern, report the neoplasm code first, followed by 338.3.
Spinal pain coding
Millions of people in the United States suffer from spinal pain and it can be very debilitating, Safian says. Spine pain includes the following diagnoses:
  • Cervicalgia (neck pain)
  • Thoracic spine pain
  • Lumbalgia (low back pain)
  • Sacroliac pain
  • Coccygodynia
  • Vertebrogenic (pain) syndrome NOS
Patients rarely suffer from whole-spine pain. Instead, the pain is generally localized to a specific area of the spine. Each spinal pain diagnosis is similarly aligned, Safian says, with different ICD-9-CM codes for each area of the spine. These codes include:
  • 723.-, cervical spine [neck] pain
  • 724.1, thoracic spine pain
  • 724.2, lumbar spine pain
  • 724.6, sacroiliac pain
  • 724.7x, coccyx pain
Pain management injection procedures
Physicians can treat chronic and acute pain using a number of different modalities, including:
  • Trigger point injections
  • Sacroiliac (SI) joint injections
  • Nerve blocks
  • Facet joint injections
  • Transforaminal injections
  • Epidural steroid injections
Coders will find some minor differences between ­coding for pain management services on the physician side and on the facility side, says Susan E. Garrison, CHCA, CHCAS, CHC, PCS, FCS, CCS-P, CPAR, CPC, CPC-H, executive vice president of healthcare ­consulting services for Med Law Advisors, Inc., in Atlanta.
Coders also need to note that more and more CPT codes include the fluoroscopy or CT portion of the invasive procedure, Garrison says. The AMA continued its trend of bundling fluoroscopy into the CPT procedure code for pain management procedures.
Trigger point injections
A trigger point is a painful area of soft tissue or surrounding muscle. The physician injects an anesthetic and/or steroid in the area to relieve the pain. Coders should report CPT code 20552 for one or two muscles or code 20553 for three or more muscles, ­Garrison says. Note that the CPT codes include multiple injections.
Report one code per session based on the number of muscles injected, not the number of injections given, Garrison says. Coders should never report 20552 and 20553 together. However, they can report fluoroscopic needle placement guidance with CPT code 77002.
SI joint injections
Historically, outpatient hospitals reported therapeutic SI joint injections using HCPCS Level II code G0260 (provision of anesthetic, steroid and/or other therapeutic agent, with or without arthrography). Hospital outpatient coders still report G0260 but do not code for the guidance, Garrison says.
For physician coding, CPT code 27096 (injection procedure for sacroiliac joint, anesthetic/steroid, with image guidance [fluoroscopy or CT]) remains the ­correct CPT code, but as of 2012, it now includes image guidance.
If the clinician does not document the use of ­image guidance, coders must go back to the trigger point ­injection codes, Garrison says. Clinicians say they don't know whether they are in the SI joint without that image ­guidance, so if they don't know they're in the joint, ­coders can't report a joint injection.
Because each patient has two SI joints, coders can append modifier -50 (bilateral procedure) to the code for the SI joint injection. However, many payers do not like modifier -50, so coders would need to report the injections on two separate line items in those cases, Garrison says.
Spinal injection procedures
If a physician performs an injection into the spine, coders will base CPT code selection on:
  • Approach: epidural, transforaminal, or facet
  • Substance: anesthetic, steroid, contrast, or ­neurolytic agent
  • Spine region: cervical, thoracic, lumbar, or sacral
  • Number and laterality of levels (or joints) injected
Epidural injections are injected directly into the epidural space between vertebrae. For an injection of a diagnostic or therapeutic agent, epidural or subarachnoid in the cervical or thoracic spine, report CPT code 62310. If the injection is made in the lumbar or sacral region, report 62311. The injection codes are unilateral codes and should be reported once per side per level, Garrison says. In addition, coders report therapeutic or diagnostic epidural injections using the same ICD-9-CM code.
If the physician uses fluoroscopy (CPT code 77003) or epidurography (72275) for localization, coders can report the imaging. These codes include use of contrast material for confirmation of needle/catheter placement. Coders should only report epidurography if the clinician documents the images and provides a formal radiological report. Fluoroscopy and epidurography should not be reported together.
For transforaminal injections (injections into the intervertebral foramen), select the appropriate CPT code from 64479 to 64484. Each vertebra includes two foramen, one on each side. These codes are unilateral, so coders can report a code for each side, Garrison says. Coders should choose the code based on the spinal level and may report codes for each level the physician injects.
Fluoroscopy is included in the transforaminal injection codes. If the physician uses ultrasound guidance instead of fluoroscopy, coders should report the appropriate category III code (0228T-0230T).
For a transforaminal epidural injection at the T12-L1 level, use 64479 (injection[s], anesthetic agent and/or steroid, transforaminal epidural, with imaging guidance [fluoroscopy or CT]; cervical or thoracic, single level), Garrison says. "I think it is a good thing they defer to 64479," she adds. "The higher up the body, the more difficult the access, so I think it is appropriate that they defer to the more complex code."
If the physician injects the substance into the facet joint, coders would select the appropriate code from 64490 to 64495. The code selection is again based on the level of the injection. Each joint includes four facet joints. Coders should report the appropriate code or codes for each level that the physician injects. Image guidance is included in the codes and should not be reported separately, Garrison says. These codes are also unilateral codes. Coders should report codes by level, not by number of injections.
Do not report the codes for third and any additional level(s) (64492 for the cervical and thoracic regions, 64495 for the lumbar and sacral regions) more than once per day.
 Editor’s note: This article was originally published in the July issue of Briefings on APCs. Email your questions to Senior Managing Editor Michelle A. Leppert, CPC-A, at

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