Vipin Bhardwaj
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Chapter 6 (G00-G99) of the ICD-10-CM coding lays the foundation for correct reporting of the disorders of the central nervous system that affect the brain and spinal cord such as Parkinson’s disease and cerebral degeneration as well as diseases related to the peripheral nervous system which includes conditions like polyneuropathy, myasthenia gravis, and muscular dystrophy.
As most of the nervous system conditions are a manifestation of other diseases, the ICD-10-CM guidelines for disease of the nervous system expand the use of combination codes for common etiologies and symptoms or manifestations (e.g. dementia with Parkinsonism now has a combination code F02.80).
The assignment of correct ICD-10-CM codes for conditions like hemiplegia or hemiparesis category G81 as well as the subcategory monoplegia of upper or lower limb should identify whether the side affected with such conditions is the dominant side or nondominant side. For ambidextrous patients, the default should be dominant. If the left side is affected the default is non-dominant and if the right side is affected the default code should be for dominant. For example, a right-handed dominant patient presents for treatment of hemiplegia of the left side, in this case, G81.94 hemiplegia, the unspecified affecting left nondominant side should be reported as the correct ICD-10-CM code for the condition.
Pain is one of the biggest reasons’ patients go to the hospital, which makes it imperative to have a proper understanding of the ICD-10-CM guidelines set for correct reporting of ICD-10-CM codes for pain. A code from category G89 for pain can be used with the codes from other categories to indicate more details about the nature of pain. A code from G89 series should not be used if the underlying cause of the pain is known unless the reason for the visit is pain control and not the management of the underlying condition. When the reason for the visit is the treatment of the underlying condition, the code for underlying condition should be used and no code from the G89 series should be used.
The correct reporting of pain conditions is further divided into categories depending upon the nature of the pain, i.e., whether the pain is acute, chronic, neoplasm related pain, post-thoracotomy, or postprocedural pain, and a code from G89 series can only be used when one of the above-listed nature, category, or reason of pain is documented in the medical record.
Let’s go over this with some examples:
Fracture: The physician treated the fracture by putting the shoulder in a sling. In this case, no code for G89 series should be reported, code S42.91XA and W19.XXXA should be reported. The patient presents for exacerbation of chronic right shoulder pain and the physician gave a steroid injection for shoulder pain management. In this case, G89.29 should be the first listed code followed by M25.511 to identify the location of pain in the right shoulder. The default nature of the postoperative or post-thoracotomy pain is acute unless otherwise specified.
Chronic pain is classified to G89.2. There is no time frame defining when acute pain becomes chronic. The provider’s documentation should be used as the guide for determining whether the pain is acute or chronic.
For example, a patient has neck pain for 5 years and they present for a steroid injection. In this case, M54.2 should be reported. Because the documentation does not specify if the patient’s neck pain is an acute exacerbation or chronic, therefore, chronic pain cannot be assigned. A patient with chronic hip pain presents for hip injection, in this case, M25.559 hip pain, as well as G89.29, should be reported in addition to indicate the chronic nature of the pain.
Pain documented as being related, associated, or due to cancer is reported using code G89.3 and depending upon the reason of the visit G89.3 should be reported as the first-listed diagnosis. If the reason for the visit is the management of neoplasm related pain and if the reason for the visit treatment of neoplasm, then the underlying neoplasm should be the first listed diagnosis.
G89.0, chronic pain syndrome should be used when the term chronic pain syndrome is clearly documented in the record and this condition is different than the term chronic pain. For example, patient with chronic shoulder pain presents for shoulder injection. In this case, M25.519 pain in the shoulder, as well as G89.29, should be reported.
A patient with chronic pain syndrome presents for physical therapy to treat the pain, in this scenario G89.0 chronic pain syndrome should be reported.To further conclude, the accurate ICD-10-CM coding for pain depends upon the provider’s documentation about the nature or cause of the pain. The coder should keep a vigilant eye within the medical records on terms like acute, chronic, neoplasm related pain, postoperative pain, post-thoracotomy pain, or chronic pain syndrome.
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