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Guidelines to follow in Coding for Postoperative Pain in ICD-10-CM

Eventually, deciding whether to report postoperative pain as an additional diagnosis relies on the documentation, which, again must specify clearly that the pain occurred is not normal or routine for the method if additional code is used. If there porting sustains a diagnosis of non-routine, critical or more pain following a procedure, then it is necessary to decide whether the postoperative pain is happening due to difficulty of the method, which also must be reported in clear terms. After this, we can allocate accurate codes.
Normally Postoperative pain is considered as a normal phase of healing method following many types of surgery. Such pain is frequently kept under control using typical measures like pre-operative, non-steroidal, provocative medications; local anesthetics that is injected into the operative wound before suturing; postoperative analgesics; and even intra-operative or post-operative injection of epidural analgesics, that form many kinds of surgeries.

When postoperative pain is documented to the current, which is far away from the routine and expected for the appropriate surgical method surgical, do you think it is a reportable diagnosis. Also note that coding for Postoperative pain in ICD-10-CM, which is not considered on daily basis or expected further in future, is categorized by whether the pain is pertaining with a definite, documented postoperative complication.

Extreme coding forPostoperative Pain in ICD-10-CM not reported due to a Specific PostoperativeComplication

Remember that Postoperative pain not related with a precise postoperative complication is conveyed with a code from Category G89, This Pain not shown or classified anywhere else.

Postoperative pain in ICD-10-CM mainly has four codes as given below.

  • G89.12 Acute post-thoracotomy pain;
  • G89.18 Other acute post-procedural pain;
  • G89.22 Chronic post-thoracotomy pain; and
  • G89.28 Other post-procedural pain that is chronic

In any case, if the documents fail to mention whether the post-thoracotomy or post-procedural pain is acute or chronic, consider the default is acute.

Extreme level of Postoperative Pain reported Due to a Specific Postoperative Complication
Any coding for Postoperative pain reported that is taking place due to a specific postoperative complication is always documented with its specified code for that particular complication that also includes Injury, poisoning and many other consequences of external causes. There is an extra additional code from category G89 that may be documented to define the pain more appropriately whether it is post-thoracotomy or other postoperative pain, which is acute or chronic in nature.

Before we get into any discussion of postoperative pain generating due to a definite postoperative difficulty, it is very crucial to fully apprehend the general guidelines pertaining to the coding of complications of care, which are described in Section I.B.16 of the draft version in year 2013 of the ICD-10-CMOfficial Guidelines and Reporting. All these guidelines are very much alike to those that are present in ICD-9-CM. The main factors to bear in mind when coding complications of care are given below:

  • Allotment of code depends on the provider’s reporting of the relationship between the situation and the medical care or method used.
  • Remember, not all conditions occurring during the course of medical care or carrying out procedures are considered as complications.
  • In any case, if you find the reporting done is not clear, you reserve the right to question the person concerned who wrote it.
Hardik Kevadiya

Hardik Kevadiya

Hardik Kevadiya is a Business Development and Marketing Manager at ezDI and Mediscribes. Hardik is passionate about Healthcare Information Technology and Innovations - Innovations that enhance human lives. He is also a healthcare trend and news follower, his passion for helping Healthcare IT professionals in all aspects of online trends and research flows through in the expert industry coverage he provides. In addition to writing for ezDI, Hardik also mentors a team of Data Analysts and Marketing professionals.

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