Postoperative pain typically is considered a normal part of the recovery process following most forms of surgery. Such pain often can be controlled using typical measures such as pre-operative, non-steroidal, anti-inflammatory medications; local anesthetics injected into the operative wound prior to suturing; postoperative analgesics; and even intra-operative or post-operative injection of epidural analgesics, for some types of surgeries.
Only when postoperative pain is documented to present beyond what is routine and expected for the relevant surgical procedure is it a reportable diagnosis. Postoperative pain that is not considered routine or expected further is classified by whether the pain is associated with a specific, documented postoperative complication.
Excessive Postoperative Pain Not Documented as Due to a Specific Postoperative Complication
Postoperative pain not associated with a specific postoperative complication is reported with a code from Category G89, Pain not elsewhere classified, in Chapter 6, Diseases of the Nervous System and Sense Organs. There are four codes related to postoperative pain, including:
G89.12 Acute post-thoracotomy pain;
G89.18 Other acute post-procedural pain;
G89.22 Chronic post-thoracotomy pain; and
G89.28 Other chronic post-procedural pain.
If the documentation does not specify whether the post-thoracotomy or post-procedural pain is acute or chronic, the default is acute.
Excessive Postoperative Pain Documented as Due to a Specific Postoperative Complication
Postoperative pain documented as occurring due to a specific postoperative complication is reported with a code for the specific complication from Chapter 19, Injury, poisoning and certain other consequences of external causes. An additional code from category G89 also may be reported to describe the pain more specifically as either post-thoracotomy or other postoperative pain, and as acute or chronic.
Before discussing postoperative pain occurring due to a specific postoperative complication, it is important to understand fully the general guidelines related to coding of complications of care, which are found in Section I.B.16 of the 2013 Draft Version of the ICD-10-CM Official Guidelines and Reporting. These guidelines are very similar to those that exist for ICD-9-CM. The key elements to remember when coding complications of care are the following:
- Code assignment is based on the provider’s documentation of the relationship between the condition and the medical care or procedure.
- Not all conditions that arise during the course of or rendering medical care or performing procedures are classified as complications.
- There must be a cause-and-effect relationship between the care provided and the condition, which must be documented by the provider.
- If the documentation is not clear, query the person who wrote it.
There are a number of postoperative complications that may be the cause either acute or chronic pain. The health record must be reviewed carefully to determine that a cause-and-effect relationship exists between the complication and the pain. Examples of postoperative complications that might cause excessive postoperative pain include:
- Postoperative infection (T81.4XX-);
- Foreign body accidentally left in body following a procedure (T81.5-); and
- Complications of prosthetic devices, implants, and grafts (T82.-, T83.-, T84.-, T85.-).
Determining whether to report postoperative pain as an additional diagnosis is dependent on the documentation, which, again, must indicate that the pain is not normal or routine for the procedure if an additional code is used. If the documentation supports a diagnosis of non-routine, severe or excessive pain following a procedure, it then also must be determined whether the postoperative pain is occurring due to a complication of the procedure – which also must be documented clearly. Only then can the correct codes be assigned.
About the Author
Lauri Gray, RHIT, CPC, has worked in the health information management field for 30 years. She began her career as a health records supervisor in a multi-specialty clinic. Following that she worked in the managed care industry as a contracting and coding specialist for a major HMO. Most recently she has worked as a clinical technical editor of coding and reimbursement print and electronic products. She has also taught medical coding at the College of Eastern Utah. Areas of expertise include: ICD-10-CM, ICD-10-PCS, ICD-9-CM diagnosis and procedure coding, physician coding and reimbursement, claims adjudication processes, third-party reimbursement, RBRVS and fee schedule development. She is a member of the American Academy of Professional Coders (AAPC) and the American Health Information Management Association (AHIMA).
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