The assessment of the nature, causes and severity of pain, together with effective pain management, has become a national health care priority.
Pain control is a determinant of patient satisfaction, an indicator of health care quality, and ultimately a component of patients' rights. Other than a patient abusing or illegally diverting medications, there are no excuses for failing to provide appropriate medications that will mitigate suffering.
The collection of data on pain, using diagnostic codes identifying the causes of pain and the circumstances in which it occurs, has therefore become a priority. Careful documentation of the causes of pain is needed to facilitate analysis of the nature and scope of pain in the U.S.
When pain is caused by a particular underlying condition, it is usually considered a symptom of the condition and does not require a separate, specific code. Examples might be pain due to acute traumatic injury, myocardial infarction, pleurisy, cholecystitis, arterial embolism, migraine or ureterolithiasis. Pain due to spinal or nerve root compression syndromes should be identified, including degenerative disc disease, herniated disc, spondylolisthesis, neuroforaminal encroachment or spinal stenosis.
Pain arising from certain conditions or circumstances is assigned specific codes for identification:
- Cancer-related pain (acute or chronic);
- Chronic post-traumatic pain;
- Postoperative pain, when chronic or inordinately severe (but routine or expected postoperative pain after surgery should not be coded);
- Chronic post-thoracotomy pain (classified separately from other postoperative pain);
- Pain related to devices or implants (usually chronic);
- Central pain syndromes, such as myelopathic pain syndrome or thalamic pain syndrome;
- Chronic pain syndrome or other specific causes of chronic pain, such as fibromyalgia, causalgia, myofascial pain syndrome, and reflex sympathetic dystrophy.
In some instances, the specific diagnosis of the underlying cause of pain is critical for correct DRG assignment, medical necessity determination and appropriate hospital reimbursement. The most frequently encountered situation is the elderly patient admitted with severe pain due to an osteoporotic vertebral compression fracture after a minor fall.
If the patient is diagnosed simply with a “compression fracture,” the DRG assigned will be “Medical Back Pain” with corresponding low reimbursement, an expected length of stay (LOS) of 3.2 to 5.0 days, and the prospect of medical necessity review with rejection of payment. However, if the problem is documented as an “osteoporotic” compression fracture, the DRG will be “Pathologic Fracture” with higher reimbursement, an expected LOS of 3.3 to 6.3 days, and typically no review for inpatient medical necessity.
Pain is not considered the principal reason for admission unless the only care provided is pain control and management. For example, if a patient is admitted for refractory pain due to bone metastases and requires a venous access catheter for opioid infusion and no direct treatment or evaluation of the cancer is needed, then cancer-related pain is the principal diagnosis and reason for admission.
When admission involves the evaluation or treatment of the underlying cause of pain, the cause is assigned as the principal diagnosis. As an example, suppose the cancer patient has a venous catheter inserted for refractory cancer-related pain but also receives a dose of IV chemotherapy while hospitalized. In this case, the cancer will be considered the reason for admission. It's important to make these distinctions clear in the patient's medical record.
In summary, precise documentation of the nature, causes and acuity of pain is necessary to ensure correct coding, DRG assignment, medical necessity of care and accurate data collection and analysis. Be as specific as possible about chronic pain of any cause, cancer-related pain, and central pain syndromes, and always identify “osteoporotic” spinal compression fractures in elderly patients.