Pain and Anxiety
Documentation and
Coding
By: Beth Sassano CPC, CPC-I, CCS-P, CPMA
DOCUMENTATION
• Providers need to make sure that their documentation
supports the code(s) that was use. This is the providers
responsibility!
• Documentation needs to support the complexity and severity
of treatment provided.
• ICD-10 documentation may significantly impact revenue if
physicians are not properly trained and motivated to
accommodate the new standards (OPTUM 2015).
GOOD DOCUMENTATION
• Since all coding and billing begin with good documentation
without it we will see more denied claims and less
reimbursement. AR will suffer.
• Providers expenditures will increase since they will need to
have more staff to “chase” denied claims. Billing staff will
have to write more appeals and spend time on the phone with
the payers.
Documentation
• Detailed documentation is pertinent to documenting a patient
visit. It tells the story of why the patient is there today and
what was done allows the provider to demonstrate the quality
of care provided and bill for his or her services.
• EPIC can help us meet the specificity needed in a particular
level of service by adding prompts to templates if necessary.
Providers should let administration know when they are
experiencing difficulty in achieving a level of detail needed to
explain the visit.
• Close communication should develop between providers,
coders, and biller.
Clinical Documentation
Improvement (CDI)
According to the Health Care Financial Management Educational
Report:
“One reason CDI is receiving new level’s of attention is the
growing importance of accurate documentation under valuebased payment models which tie payment to the achievement of
quality and performance targets. Accurate complete
documentation is important not only for establishing a baseline
of patient health, but also demonstrating the efficacy of the
prescribed plan of care in improving the patient’s status”
Coordinating Documentation, Coding,
and Billing
The foundation to a successful transition to ICD-10 is
documentation. As an organization we need to take the
following steps:
• Ensure provider participation and compliance.
• Create organized communication to staff and providers.
• Engage our technology.
• Perform clinical documentation assessments.
• Develop a monitoring and improvement program that
supports improvement.
Anxiety
Anxiety is a feeling of uncontrollable nervousness, fear,
apprehension, and worry that can range from mild unsettling to
severe debilitation. Anxiety occurs normally in everyday life and
is useful when alerting a person to danger, but it becomes
concerning when it disrupts normal activities. The exact cause of
anxiety is unknown, but it is believed stress may be one trigger.
Forms of ANXIETY
• Generalized anxiety disorder (300.02) — involves six months of
persistent, excessive, and unrealistic worry.
• Panic disorder (300.01) — may have a sudden onset causing
apprehension, fear, or terror. Physical symptoms may include shortness
of breath, heart palpitations, or chest pain, causing a person to think he
or she is having a heart attack. If the panic attack is associated with
agoraphobia (fear of places or situations where someone feels trapped
or helpless), assign code 300.21.
• Obsessive-compulsive disorder (300.3) — involves persistent,
recurring thoughts/impulses (obsessions) and ritualistic actions
(compulsions). This is different than obsessive-compulsive personality
disorder (301.4).
• Posttraumatic stress disorder (309.81) — occurs after a severe
emotional or physical trauma and involves the feeling that the person is
re-experiencing this traumatic event.
FORMS of ANXIETY
• Social phobia (300.23) — a person may experience anxiety
when exposed to certain social events and desires to avoid the
situation.
• Other phobia (300.2x) — anxiety when exposed to a specific
object or situation and the desire to avoid it.
• Alcohol-induced anxiety (291.89)
• Drug-induced anxiety (292.89)
• Separation anxiety (309.21) — occurs when a child is separated
from his or her parents.
• Acute stress disorder (308.3) — includes similar symptoms to
posttraumatic stress disorder but occurs immediately after a
traumatic event.
ANXIETY WITH DEPRESSION ICD-9
A diagnosis of anxiety is usually made with a physical
examination and psychological evaluations.
Anxiety may be associated with depression. If both are
documented by a provider, assign codes 311 and 300.00.
However, if the provider links the two conditions, such as
“depression with anxiety,” then code 300.4, Dysthymic disorder,
may be assigned (AHA Coding Clinic for ICD-9-CM, 2001, third
quarter, page 6).
ANXIETY IN ICD-10
• Anxiety is classified to ICD-10-CM category F41 and is similar
in structure in ICD-10-CM as in ICD-9-CM; one difference is
anxiety with depression. Two codes are available depending
on severity: F34.1, Persistent anxiety depression, and F41.8,
Anxiety depression (mild or not persistent).
• Dysthymic disorder also is classified to code F34.1 and
includes depressive neurosis, depressive personality disorder,
dysthymia, neurotic depression, and persistent anxiety
depression.
Anxiety Fast Finders
Coding and Documenting
Depression
In ICD-10-CM, coding for depression requires specific documentation as
to:
•
Type and Acuity.
The default for unspecified depression is major depressive disorder,
single episode (F32.9), which includes depressive disorder not
otherwise specified (NOS) and major depression NOS.
Physician education and coding inquiries for clarification will be needed
to accurately document the type and acuity of depression.
This will avoid misrepresentation of a less severe disorder as a major
one.
Depression Fast Finder
Pain
Medical knowledge related to pain and pain syndromes has led to
new classifications and codes for the various types of pain.
Frequently reported codes for pain and pain syndromes are
found in two ICD-10-CM chapters:
• Chapter 6 – Diseases of the Nervous System
• Chapter 13 – Diseases of the Musculoskeletal System and
Connective Tissue
Commonly Treated Pain Diagnoses
Found in Chapter 6
• Migraine and other headache syndromes (categories G43G44)
• Causalgia (complex regional pain syndrome II) (CRPS II) (G56.4, G57.7-)
• Complex regional pain syndrome I (CRPS I) (G90.5-)
• Neuralgia and other nerve, nerve root and plexus disorders
(categories G50-G59)
• Pain, not elsewhere classified (category G89)
Pain Disorders Related to Psychological Factors
ICD-10
Assign code F45.41, for pain that is exclusively related to
psychological disorders. This must be CLEARLY documented.
Do not assign a code from category G89 if there is
documentation of psychological component for a patient with
acute or chronic pain.
PAIN G89
G89 – Pain not elsewhere classified 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.
A code from category G89 should not be assigned if the underlying
diagnosis is known UNLESS the reason for the visit is pain management
and NOT management for the underlying condition.
If the pain is not specified as acute or chronic, post-thoracotomy, postprocedural, or neoplasm related, DO NOT assign a code from G89
A code from G89 should not be assigned if the definitive diagnosis is
known unless the reason for the visit is pain control or management
and not management for the underlying condition.
G89
This category includes:
• Central pain syndrome,
• Acute pain not elsewhere classified,
• Chronic pain not elsewhere classified,
• Neoplasm related pain, and
• Chronic pain syndrome.
G89 as the Primary Diagnosis
G89 is acceptable as the primary dx when:
• Pain control or pain management is the reason
for the office visit. The underlying cause of the
pain should be documented in the EMR and
reported as additional diagnosis if known.
• Code first the G89 followed by the condition
causing the pain.
Site Specific Pain Codes
G89 may be used in conjunction with codes that identify the site of pain
(including codes from chapter 18) if the category G89 provides
additional information. For example if the code describes the site of
pain but does not describe if it is acute or chronic, both codes can be
assigned.
Sequencing:Is dependent on the circumstances of the visit.
• If the visit is for pain control or management. Assign G89 followed
by the code identifying the pain. E.g. Acute pain due to trauma,
followed by M54.2, cervicalgia
• If the visit is for any other reason except pain control or
management and a related definitive dx. has not been established or
confirmed by another provider, assign the code for the specific site
of pain first, followed by the appropriate code from category G89
Chronic PAIN
There is no time frame defining when pain
becomes chronic.
Provider documentation should be used as the
guide for assigning a code for chronic pain.
Chronic pain is classified to subcategory G89.2
Central Pain Syndrome
(Chronic vs Central)
Central pain syndrome, G89.0 and Chronic
pain syndrome, G89.4 are different than the
term “chronic pain” and therefore codes
should only be used when the provider has
specifically documented this condition.
Pain Fast Finder
Migraine and Other Headache
Syndromes
In ICD-10-CM, the various types of migraines are reported with codes in category G43.
All migraines must be documented as intractable or not intractable and with status migrainosus or without
status migrainosus. Migraine with aura = classic, migraine without = common
Status migrainosus refers to a rare and severe type that can last 72 hours or longer. The pain and nausea
are so intense that people who experience this type of headache often need to be hospitalized.
Additionally, certain medications, or medication withdrawal can cause this type of migraine
Intractable migraine is a migraine type that has some of the common signs of simple headache in addition
of vertigo. Changes in the inner ear are the main factor for this vertigo. It is responsible for your body
balance. When this vertigo happens the stand or walk ability is changed.
Simple migraine type is a headache which occurs on of one side of our heads, and it is painful. Aura and
visual disturbances may be occurred before this painful headache phase in this simple migraine and many
other migraine forms such as intractable and ocular migraine ( it is also named as a vestibular, ocular,
painless, eye, visual and silent migraine ).
Migraine and Other Headache
Syndromes
Terms that describe intractable migraine
include:
• pharmacoresistant or pharmacologically
resistant,
• treatment resistant,
• refractory, and
• poorly controlled.
Migraine and Other Headache
Syndromes
Other headache syndromes are reported
with codes from category G44 and include:
cluster headaches, vascular headache not
elsewhere classified, tension-type
headaches, post-traumatic headaches, druginduced headaches, as well as others.
Migraine and Other Headache
Syndromes
Other headache syndromes are reported
with codes from category G44 and include:
• cluster headaches,
• vascular headache not elsewhere
classified,
• tension-type headaches,
• post-traumatic headaches,
• drug-induced headaches
Migraine Fast Finder
Abdominal Pain Documentation
There is a one to one crosswalk from ICD-9 (789.00) to ICD-10 (R10.9)
for abdominal pain unspecified site and unspecified abdominal pain.
It is important for the provider to document the location of the pain.
• Upper and lower abdomen (horizontal line about the level of the
umbilicus)
• Right side upper and left side upper
• Right upper and left side upper
• Pelvic area (right and left)
Additionally, it is crucial that the provider document exactly what the
findings are, if any, to accurately record the exact course of action for
the condition presented or defined after study, as well as for the
coding and billing process.
Abdominal Pain in EPIC
Causalgia
Accurate Documentation Required
Causalgia, also referred to as complex regional pain syndrome
type II (CRPS II), is a type of neuropathic pain that occurs
following a distinct nerve injury, usually to a peripheral nerve in
an extremity.
Causalgia of the upper limb is reported with codes in subcategory
G56.4-.
Causalgia of the lower limb is reported with codes from
subcategory G57.7-.
Fifth characters for both the upper and lower limbs identify
laterality as unspecified (0), right (1), left (2).
Complex Regional Pain
Syndrome I (CRPS I)
Complex regional pain syndrome I is the most common type of CRPS.
CRPS II (causalgia) it is a type of neuropathic pain that usually occurs
following an injury to an extremity. However, in CRPS I there is no direct
injury to a nerve.
It can occur following an illness or it can occur without any known
cause.
CRPS I is reported with codes from subcategory G90.5. Codes are
specific to the upper and/or lower limbs and laterality.
Detailed documentation is required.
Chapter 13 – Diseases of the
Musculoskeletal System and Connective
Tissue
Many pain conditions are a result of musculoskeletal or
connective tissue disorders and diseases. Codes for these
conditions are found in Chapter 13 of ICD-10-CM.
An example of pain classified in Chapter 13 is radiculopathy
associated with disorders and diseases of the spine. These
conditions are found in block M40-M54 –
Dorsopathies.
Other conditions related to pain medicine that are classified in
Chapter 13 include, cervicalgia, sciatica, low back pain with and
without sciatica, thoracic spine pain, joint pain, muscle spasm,
myalgia, and fibromyalgia
Documenting Underdosing
Underdosing. Underdosing is a new code in ICD-10. It identifies
situations in which a patient has taken less of a medication that
was prescribed by the provider. The medical condition or
diagnosis is sequenced first, with the underdosing code listed as a
secondary diagnosis.
“The additional code tells us why the patient isn’t taking their
medication.”
Since this is new, many physicians will not be in the habit of
documenting a patient’s reasons for underdosing in the record.
Underdosing
For underdosing, assign the code from categories T36 – T50 found in
Chapter 19. These codes require a 7th character extension to describe
an initial encounter (A), subsequent encounter (D), or sequela
encounter (S).
Underdosing codes must be identified in the following order:
• The medical condition is sequenced first. The first-listed code would
be the event that is triggered or prolonged due to this circumstance.
• The underdosing code is listed as the secondary code assignment.
Codes for underdosing should never be assigned as principal or
first-listed codes.
• The additional code explains why the patient is not taking the
medication(s). Financial hardships and age-related debilities are
some examples of underdosing.
Example
• A patient is prescribed the antibiotic tetracycline to treat a UTI
(urinary tract infection). The patient did not take the
medication as prescribed, which resulted in pyelonephritis
(kidney infection).
CODE:
• N10 Acute tubulo-interstitial nephritis (The first-listed code would
be the event that is triggered or prolonged due to this
circumstance.)
• T36.4x6A Underdosing of tetracyclines, initial encounter (The
underdosing code would be the secondary code assignment)
Partnership
As stated earlier in this presentation there is
clear correlation between what the provider
documented and what is report by the
coder.
Open communication is essential between
both the provider and the biller/coder to
ensure the provider is being adequately
compensated for their work effort!
Thank YOU
?
References
• Code It Right online news letter – March 2013
• Online article by Audrey Howard RHIA – 3M consulting
Services
• AHIMA – Online For the Record 10/8/2012
• AAPC website: “Documentation will become critical with ICD10”
• Towers, Adele L. “Clinical Documentation Improvement – A
physician Perspective: Insider Tips For Getting Physician
Participation in CDI Programs.” Journal of AHIMA 84, no 7
(July 2013): 34-41
• HFMA Educational Report, “The right documentation Strategy:
Improving Your Clinical and Financial Performance” June 2013