Coding Chronic Pain Syndrome

“Chronic pain syndrome” can be considered as a vague description of a vague diagnosis by your carrier and unless you back up your medical billing with the reasons for using this catchall term for several pain conditions, you may be seeing only partial reimbursements to denials for this condition. Traditionally, ICD-9 directs you to code 338.4 (Chronic pain syndrome) for the condition.

However, you may need to couple this diagnosis with other probable causes backed up by symptoms and doctor’s notes. Other diagnosis possibilities for chronic pain syndrome include fibromyalgia/muscular pain (729.1, Myalgia and myositis, unspecified); reflex sympathetic dystrophy/regional pain syndrome (337.2x, Reflex sympathetic dystrophy) or peripheral neuropathy (337.0, Idiopathic peripheral autonomic neuropathy) caused by either diabetes (250.6x, Diabetes with neurological manifestations) or amyloidosis (277.30, Amyloidosis, unspecified). Among the listed alternatives for 338.4, coders choose 729.1 most commonly as a substitute for the generic chronic pain syndrome diagnosis code.

The best route to getting a better reimbursement on a vague diagnosis is to check with your physician to clarify what type of pain the patient has. The patient might initially report pain “everywhere” but he may be able to pinpoint his worst pain sites, such as the lower back (724.2, Lumbago) or the hip (719.45, Pain in joint; pelvic region and thigh).

Also it’s a good practice to verify any of the patient’s pain-related symptoms before reporting the physician’s final diagnosis. Good examples of those would be back muscle spasms (724.8, Other symptoms referable to back) or derangement of joint (718.95, Unspecified derangement of joint; pelvic region and thigh).

When in doubt, ask the attending physician which diagnosis in their opinion best suits the claim. Using the notes can help you also pin it down and if you show that you have a vague claim that needs more exacting information to get a better reimbursement for the practice, putting the need for exact information in dollars and cents is usually a good way to get the proper information you need to process the claim for the best return on services for the physician.

View all Articles by: Melissa Clark, CCS-P