Today I'm going to talk about Chapter 6
guidelines for the codebook. There were no
changes to Chapter six in 2017 so you
can use those guidelines directly in
front of the chapter in your code book
when you're doing your homework. The
first guideline has to do with dominance,
whether a patient's dominant and
non-dominant side is affected by the
hemiplegia. In this scenario, a right spastic
hemiplegia is documented, unknown
whether the patient is right or left hand
dominant so our guidelines tell us
should the affected side be documented but
not specified as dominant or non
dominant, you're going to follow this
classification system. If the right side
is affected, the default is dominant. That
tells us that the fifth character in our
code would be "1" indicating right side
dominance. In the next guideline,
hemiplegia affecting the left side of an
ambidextrous patient, the guidelines tell
us for ambidextrous patients, the default
should be dominant. What that means is
that if they're ambidextrous, both sides
are equally strong so whatever side is
affected, in this case the left side,
we're going to say the left side is
dominant. Now, let's talk about general
coding information in this next coding
guideline. We can use codes in category
G89 along with codes from other
categories and other chapters if the G89
code provides more detail. For example,
if the scenario given to us does not
tell us if the pain is acute or chronic and we
have G89 codes that say so,then we
would use those G89 codes. If the pain
in your documentation is not
specified as acute or chronic, not
specified as post-thoracotomy,
post-procedural or neoplasm-related,
we do not assign codes
from category G89. It has to
have those terms in order for us to use
that category.
Also, a code from category G89 should not
be assigned if the underlying diagnosis
is known unless the reason for the
encounter is pain control. We will go over a few
examples of that and get into more detail.
A little more coding information, if an
admission is for a procedure aimed at
treating the underlying condition, the
underlying condition is the principal
diagnosis, not a code from G89.
Oftentimes, pain is integral to any
procedure or surgery so unless the
physician has documented that the pain is
in excess of what one would expect, we
would not very often code pain. So you
really have to pay attention to
documentation. Here's an example of when
we could use G89 category codes as our
principal (diagnosis). Patient presents for steroid
injection for control of pain of a
chronic right knee due to primary
degenerative joint disease (also
abbreviated DJD. When you look up DJD
in the index, it takes you to "osteoarthritis"
so you can go to osteoarthritis when you see
that medical term DJD. In this case,
though the patient's presenting for
control of pain, not for treatment of a
DJD so the G89 code would be the
principal (diagnosis) because the patient's
presenting for control of the pain. If
you think about a lot of guidelines, it
really is "what is the encounter or is
the admission for?" Depending upon where
your treatment is directed, it's going to
help you determine what the principal
diagnosis should be. The guidelines help
you with that as well but if you can
just keep that in mind. (The question is) where is the
treatment directed? It helps you really
decide what the principal diagnosis
should be. In this scenario, the patient
is seen to evaluate chronic left
shoulder pain. You're evaluating the pain.
What the guidelines tell it is a G89
would be used in conjunction with codes
that identify the site of
pain if a category code provides more
information. So even though the patient
is being seen to evaluate the pain, that
pain in the shoulder is going to be the
principal diagnosis but the pain in the
shoulder does not tell the doctor or the
reader if the pain is acute or chronic and
because we have a chronic pain code for
specified sites, we would use it in this
example. G89.29 We're using
that G89 category code because it
provides additional information.
When you are looking at the sequencing
of codes with site-specific pain codes,
again, it depends on what you're being
seen for. This is telling us the patient
is seen for management of acute
traumatic right knee pain. The patient's
being seen not to treat the knee, but to
manage the pain, so the pain code, acute
pain due to trauma, would be the
principal diagnosis and a pain in the
joint (code) would also be there to identify
the site. The coding guidelines tell us
how we would sequence those codes. Assign
the code for category G89 followed by the
code identifying the specific site of
pain. Here's another example. Tests are
performed to investigate the source of the
patient's chronic epigastric abdominal
pain. The pain is being investigated but
because we don't know a diagnosis, we
would code the symptoms from Chapter 18
in our code book. There is a code for
upper epigastric abdominal pain (R10.13).
We would also add the G89 code because
that tells the doctor and the reader
that the pain is chronic.
Now, some general information about
post-operative pain. The provider's
documentation should be used to guide
the coding of post-op pain as well as
information contained in your code book
in Section III and Section IV. Please take
the time to go there. Read the guidelines,
those at the beginning of the code book
or in the case of our 2017 codebook,
we would go to the beginning of the PDF
or the Word document that you're using
and read through those times when we
would report additional diagnoses or when
we're reporting in the outpatient
setting. As I mentioned earlier, pain is
associated with a procedure most of the
time but we still have to be cognizant
of the fact that there are times when we would want
to code it. The default for post -thoracotomy
and other post-op pain not
identified as acute or chronic is to use
the acute form of pain, not the
chronic form of pain. Routine or expected
post-op pain immediately after
surgery should not be coded.
Here's an example. Patient's pain pump, the
dosage is increased for unexpected
extreme pain post-thoracotomy. There is
a pain code for post-thoracotomy and the
default, because we're not saying if it's
acute or chronic in the scenario, we would
code it. I can't imagine how much that hurts
because you're actually going through
the patient's chest, often going through
the ribs, so it would have quite a bit of
pain associated with a thoracotomy.
That's why there is a unique code for it. I
bring this slide to your attention just to
point out that chronic pain and chronic
pain syndrome (central pain syndrome)
Those are different things so be very
careful in your reading of documentation
that you are picking up the right term
with regards to chronic pain. There's
no time frame with that. There's no
definition of, if your pain's lasted more
than a year, it is now classified as chronic....
there's no documentation and no
guidelines around that. So you're just
going to depend on your provider's
documentation to guide your use of the
code for chronic pain. Chronic
pain syndrome G89.4 and central pain
syndromes G89.0 are different than the
term chronic pain so if your
documentation states those things, you
would be looking specifically for those
diagnoses and not a chronic pain
diagnosis. It also refers us to Chapter 5
in the guidelines in the
codebook for pain disorders related to
psychological factors. Sometimes chronic
pain is believed to be related to
psychological factors where you would be
adding that F45.42 code.
Now let's talk about pain related to
malignancies or neoplasms. Code G89.3 is
a code that specifically states pain due
to cancer, pain due to malignancy. It
doesn't matter if the pain is acute or
chronic in those cases. If it's related
to malignancy, you're just going to add
it to document the patient does have
pain related to the malignancy. If the
pain related to the malignancy is a
reason why the patient is being treated,
that would be your principal diagnosis
and the cancer diagnosis would be
reported as an additional code. If the
reason for the admission was to manage
the neoplasm, but the patient has pain
associated with the neoplasm, that code
G89.3 would be assigned but it would not
be the principal (diagnosis). The principal diagnosis would be
the code for the cancer. You see, in
italics, it refers us back to the
Neoplasm chapter, Chapter 2 in the code
book to review those guidelines as well.
Here's an example. Patient is admitted
for pain medication adjustment for
chronic pain from bone metastasis. The
admission is for the pain due to the
malignancy so that would be your principal
diagnosis (G89.3). We would assign the
bone cancer, which if it's a metastasis,
it's a secondary malignant code so going
to the Table of Neoplasms, you would see
"bone" and then the column that says
secondary malignant and that would be
C79.51 would
be your additional code or your
secondary code. Notice again that the
reason for the encounter or admission
is what determines your principal
diagnosis. In this example, the patient
with lung cancer presents with acute hip
pain evaluated and found to have iliac
bone metastases. The pain is being
evaluated but really, it's the cancer
that's driving the admission so the
secondary malignant bone
would be your principal diagnosis,
followed by the primary malignancy code,
and then the pain due to malignancy. If you
remember from a previous guideline, it doesn't
matter if it's acute or chronic, if it's
pain related to malignancy, you just
state the G89.3 code. If you have any questions
about the Chapter 6 guidelines, please post
them in the discussion board. As with all
of these podcasts, I encourage you to
watch them more than once because I'm
hoping by hearing them, you will be
reminded when you're doing homework that
there is a guideline related to those
things. Also, as a reminder, I don't cover
all the guidelines in the podcast. They
would simply be too long but I am
hitting on those that we would find
most often in acute care. Thank you so
much. Have a nice evening.