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December 11, 2006
It was surprising to see the amount of attention given to pain codes this fiscal year (FY). Historically, pain has been relegated to the lowly Chapter 16 for Symptoms, Signs, and Ill-defined Conditions in ICD-9-CM (International Classification of Disease, Ninth Revision, Clinical Modification). Anyone who is in pain will attest to the fact that it is not ill-defined at all and is generally quite eager to define it for you at length. Coding in FY 2007 will promote several specific types of pain to Chapter 6 with codes for Nervous System and Sense Organs. As diagnosis-related group (DRG) coders are quick to realize, the immediate impact of a code change from one chapter to another generally includes a DRG change as well—if the associated problem qualifies as a principal diagnosis for an inpatient admission. First in line for the new three-digit category is 338.0 Central Pain Syndrome. What type of documentation would you expect to see in association with this diagnosis? This syndrome is the result of either dysfunction or damage to the central nervous system—brain, brainstem, and spinal cord—and is manifested by numerous pain types and sites. The cause may be stroke or tumor, trauma to the central nervous system, or degenerative nervous system diseases such as multiple sclerosis and Parkinson’s disease. Since the causes are so varied, so is the presentation of the pain itself. The pain, usually constant, can range from sharp or stabbing to aching or burning and even to numbness or a pins-and-needles sensation. Onset often begins soon after injury or onset of disease, but it may not manifest itself until a significant amount of time has passed. Several acute pain codes present themselves next, followed by matching chronic pain pairs: • 338.11 Acute pain due to trauma; • 338.12 Acute post-thoracotomy pain; • 338.18 Other acute postoperative pain; • 338.19 Other acute pain; • 338.21 Chronic pain due to trauma; • 338.22 Chronic post-thoracotomy pain; • 338.28 Other chronic postoperative pain; and • 338.29 Other chronic pain. Expect documentation issues when you need to validate the specificity of acute and chronic pain for the above diagnoses. If you look up chronic in Stedman’s Medical Dictionary, you will learn that the United States National Center for Health Statistics defines a chronic condition as one with a duration of three months or longer. Acute, on the other hand, is defined as a usually rapid-onset, brief, and not prolonged, and possibly meant as severe. Rarely, however, will you have the information to pin down the variant of the pain. Are coders to presume that pain from a recent trauma is acute and pain from a cancer of three or more months of duration is chronic? Could the tumor pain be of recent and rapid onset even though the tumor itself is longstanding? Be prepared to have extra query forms made up if you need to (all together now) “refer to the physician for further clarification.” Cancer patients often present for treatment of pain and, at last, coders are not limited to reporting it by site. 338.3 Neoplasm related pain (acute) (chronic) doesn’t care whether the pain is acute or chronic, just that it’s due to cancer. Last in the new pain category is Chronic Pain Syndrome 338.4, a diagnosis that is more difficult to categorize than it is to code. While chronic pain is a common complaint, qualifying as a syndrome presents more of a medical and coding challenge. The cause is unclear and often speculative; the syndrome itself is poorly defined. Published sources may use ongoing pain of at least six months of duration to be indicative of the diagnosis of chronic pain syndrome, but others consider a three-month minimum to meet criteria. It may be a learned response to pain from an initially noxious source, but continued occurrence can be without apparent cause once the original physical source is resolved or removed. This leads to the possibility that social or psychological factors may contribute to the syndrome’s final chronic status. If medicine can’t agree on a definition for some of the new diagnosis codes, getting the documentation to support the code usage may very well be … well, painful. If you can’t validate it to one of the codes mentioned thus far, you will have to code your own pain back to the symptom chapter. This brings us full circle to the initial question of why is there a new focus on pain codes in the first place. Think back to the last time you went to your local physician for anything that involved pain. Did they make you look at a list of smiling and frowning faces and rate your pain on a scale of one to 10? Can you actually do that based on a scale that features a smirking circle for no pain and a crying orb for the worst pain you’ve ever had? It must be subjective to use this type of criteria. A person who is younger and much less clumsy than me may think thumping a thumb with a hammer hits a 10 on this pain scale. The cancer patient with bone pain refractive to morphine will probably take exception to this comparison to his or her own worst pain experience. If you try to disregard the rating challenge, you may meet insistence that you choose one of the ratings to move along in the history and physical portion of your exam. All sorts of quality-of-care indicators are paying attention to the patient’s pain and the caregiver’s response to that pain. In the end, it’s really the patient’s perception of pain that makes the difference in the guidelines. A stoic patient, or one less sensitive to pain than others, is graded by their disturbance to pain, not its severity compared with someone else’s experience. It is even being regarded as the fifth vital sign in some facilities and is as critical a measurement as blood pressure, respiratory rate, temperature, and pulse in a hurting patient. The new pain codes will certainly present their own documentation challenges. But the significance of pain in the healthcare experience is finally getting the attention it has always deserved, and coders as well as data researchers will finally have the ability to report their variances in the coming year. — Judy Sturgeon, CCS, is the hospital coding senior manager at The University of Texas Medical Branch in Galveston. While her initial education was in medical technology, she has been in hospital coding and appeal management for the past 18 years.
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