December 17, 2020

Question:
We had a patient who came in for management of chronic right hip pain. I am new to pain management coding and not sure what diagnosis code to use. Can you help?

Answer:
Certainly. First based on the ICD-10-CM Official Guidelines for Coding and Reporting the first listed diagnosis code is G89.29 for chronic pain and you will need a secondary diagnosis to identify the site of pain (right hip) which is M25.551. Sequencing is important. Make sure before you report chronic pain it is documented as chronic in the medical record. Per ICD-10-CM Guidelines: “A code from category G89 should not be assigned if the underlying (definitive) diagnosis is known unless the reason for the encounter is pain control/ management and not management of the underlying condition. Category G89 codes are acceptable as the first-listed diagnosis code when:

• Pain control or pain management is the reason for the admission/encounter.
• The underlying cause of the pain should be reported as an additional diagnosis, if known.”

*This response is based on the best information available as of 12/17/20.