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Guidelines to follow in Coding forPostoperative Pain in ICD-10-CM

Normally Postoperative pain is considered as a normal phase of healingmethod following many types of surgery. Such pain is frequently kept undercontrol using typical measures like pre-operative, non-steroidal, provocativemedications; local anesthetics that is injected into the operative wound beforesuturing; postoperative analgesics; and even intra-operative or post-operativeinjection of epidural analgesics, that form many kinds of surgeries.

When post operative pain is documented to the current, which is far awayfrom the routine and expected for the appropriate surgical method surgical, doyou 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, iscategorized by whether the pain is pertaining with a definite, documentedpostoperative complication.

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

Remember that Postoperative pain not related with a precisepostoperative complication is conveyed with a code from Category G89, This Painnot 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-thoracotomyor post-procedural pain is acute or chronic, consider the default is acute.

Extreme level of PostoperativePain reported Due to a Specific Postoperative Complication

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

Before we get into any discussion of postoperative pain generating dueto a definite postoperative difficulty, it is very crucial to fully apprehendthe general guidelines pertaining to coding of complications of care, which aredescribed 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 tothose that are present in ICD-9-CM. The main factors to bear in mind whencoding complications of care are given below:

  • Allotment of code depends on theprovider’s reporting of the relationship between the situation and the medicalcare or method used.
  • Remember, not all conditions occurringduring the course of medical care or carrying out procedures are considered ascomplications.
  • In any case, if you find the reportingdone is not clear, you reserve the right to question the person concerned whowrote 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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