One of the coders posed a question to me about the use of the 338 codes for our Pain Management Clinic.  We are not getting documentation from the physician that pain is acute or chronic.  He gives the diagnosis of the 700 codes (721.0, 722.0, 723.0, 723.1, and 723.4).  The coder wants to query the physician for a specifics to use the 338 code as primary.  She feels that because they are coming in for treatment of the pain the 338 codes are to be used.  Since this is a pain clinic I’m not sure if this is correct or not.

From ICD-9 and AHIMA

Several established guidelines provide guidance on the use of these codes as well. Examples of these underlying principles are:

• Signs and symptoms—codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider (I. B. 6).
• Conditions that are an integral part of a disease process—signs and symptoms that are integral to the disease process should not be assigned as additional codes, unless otherwise instructed by the classification (I. B. 7).

Codes from category 338 may be used in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain and neoplasm-related pain. If the pain is not specified as acute or chronic, do not assign codes from category 338, except for post-thoracotomy pain, postoperative pain, or neoplasm-related pain. For example a patient with chronic abdominal pain would be coded to 789.00 and 338.29, while a patient with abdominal pain would be coded to 789.00.

A code from subcategories 338.1 and 338.2 should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control or management and not management of the underlying condition. It is very important that coding professionals review, understand, and apply this guideline so that these codes are not overutilized. For example, a patient diagnosed with chronic abdominal pain due to chronic cholelithiasis would be coded to 574.20, while a patient who is being treated with spinal cord stimulation because of chronic pain syndrome due to thoracic spondylosis with myelopathy would be coded to 338.4 and 721.41.

Principal or First-Listed Diagnosis

Category 338 codes are acceptable as the principal diagnosis (or first-listed code) for reporting purposes in two instances: when the related definitive diagnosis has not been established (confirmed) or when pain control or pain management is the reason for the admission or encounter. Take for example a patient who has a displaced lumbar intervertebral disc and acute back pain and presents for injection of steroid into the spinal canal. This encounter would be coded to 338.19 and 722.10.

Use of Category 338 Codes with Pain Codes

Category 338 should be used in conjunction with site-specific pain codes (including codes from chapter 16) if category 338 codes provide additional information about the pain, such as if it is acute or chronic. The sequencing of category 338 codes along with site-specific pain codes (including chapter 16 codes) depends on the circumstances of the encounter or admission and must follow these guidelines:

• If the encounter is for pain control or pain management, assign the category 338 code followed by the specific site of pain. For example, an encounter for pain management for acute neck pain from trauma would be coded to 338.11 and 723.1.
• If the encounter is for any reason other than pain control or management, and a related definitive diagnosis has not been established by the provider, assign the code for the specific site of pain followed by the appropriate code from category 338. For example, an encounter for acute neck pain from trauma would be coded to 723.1 and 338.11.

Postoperative Pain

When postoperative pain is not associated with a specific postoperative complication, it is assigned to the appropriate postoperative pain code in category 338. Postoperative pain from a complication (such as a device left in the body) is assigned to the appropriate code(s) found in chapter 17, Injury and Poisoning. In this case the code such as 998.4, Foreign body accidentally left during a procedure, would be the definitive diagnosis, and no additional code would be assigned from category 338. If, however, the patient is being seen for pain control or management, a code from category 338 should be assigned as the principal or first-listed diagnosis as stated above. If using a code in the 996.7 subcategory, a note indicates that the appropriate pain code should be assigned as an additional code.

Postoperative pain may be reported as the principal diagnosis when the reason for the encounter is postoperative pain control or management. It may be assigned as a secondary diagnosis code when the patient presents for outpatient surgery and develops an unusual or inordinate amount of postoperative pain. Post-thoracotomy pain can be classified as acute (338.12) or chronic (338.22). The default code for post-thoracotomy and other postoperative pain not stated as acute or chronic is to code the acute form.

Special note: Routine or expected postoperative pain immediately after surgery should not be coded, and the provider’s documentation should guide the coding of postoperative pain.