ICD-10-CM contains over 30 different codes in category R10 for various types of abdominal and pelvic pain. However, reimbursement for this vague code is likely to be problematic, so try to obtain a more specific diagnosis whenever possible. The ICD-10-CM Index indicates that pain NOS is reported with code R52 (Pain, unspecified). However, keep in mind that this guidance was issued for ICD-9-CM, not ICD-10-CM. For example, if the clinical history for a hand x-ray simply states “Pain,” it is appropriate to code hand pain. In a 2004 letter to the American College of Radiology, the AHA Central Office ™ stated that it is acceptable to assign the code for pain of the site that is being imaged when the requisition does not indicate the location of the pain. This constitutes poor documentation, and the department or facility should ask the ordering physician to provide a more specific clinical history, such as pain in knee joint, flank pain, precordial pain, etc. Sometimes the radiology department or imaging center will receive a requisition that simply states “Pain” without specifying the location of the pain. Remember that you should always look up the patient’s diagnosis-as documented by the physician-in the ICD-10-CM Index and follow whatever instructions it provides. We’ll discuss all three types of pain codes in this article.
In this article we’ll give you a run-down of how pain is classified in ICD-10, as well as the rules for sequencing the pain codes.
Once ICD-10 is implemented on October 1 of next year, radiology coders will need to be ready to assign the appropriate codes for these studies. Many imaging studies are ordered because the patient is experiencing pain. This article appeared in the January issue of the Radiology Coding & Compliance Expert.
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