Pain and AnxietyDocumentation and CodingBy: Beth Sassano CPC, CPC-I, CCS-P, CPMA

DOCUMENTATION• Providers need to make sure that their documentation

supports the code(s) that was use. This is the providers responsibility!

• Documentation needs to support the complexity and severity of treatment provided.

• ICD-10 documentation may significantly impact revenue if physicians are not properly trained and motivated to accommodate the new standards (OPTUM 2015).

GOOD DOCUMENTATION• Since all coding and billing begin with good documentation

without it we will see more denied claims and less reimbursement. AR will suffer.

• Providers expenditures will increase since they will need to have more staff to “chase” denied claims. Billing staff will have to write more appeals and spend time on the phone with the payers.

Documentation• Detailed documentation is pertinent to documenting a patient

visit. It tells the story of why the patient is there today and what was done allows the provider to demonstrate the quality of care provided and bill for his or her services.

• EPIC can help us meet the specificity needed in a particular level of service by adding prompts to templates if necessary. Providers should let administration know when they are experiencing difficulty in achieving a level of detail needed to explain the visit.

• Close communication should develop between providers, coders, and biller.

Clinical Documentation Improvement (CDI)According to the Health Care Financial Management Educational Report:

“One reason CDI is receiving new level’s of attention is the growing importance of accurate documentation under value-based payment models which tie payment to the achievement of quality and performance targets. Accurate complete documentation is important not only for establishing a baseline of patient health, but also demonstrating the efficacy of the prescribed plan of care in improving the patient’s status”

Coordinating Documentation, Coding, and BillingThe foundation to a successful transition to ICD-10 is documentation. As an organization we need to take the following steps:• Ensure provider participation and compliance.• Create organized communication to staff and providers.• Engage our technology.• Perform clinical documentation assessments.• Develop a monitoring and improvement program that

supports improvement.

Anxiety

Anxiety is a feeling of uncontrollable nervousness, fear, apprehension, and worry that can range from mild unsettling to severe debilitation. Anxiety occurs normally in everyday life and is useful when alerting a person to danger, but it becomes concerning when it disrupts normal activities. The exact cause of anxiety is unknown, but it is believed stress may be one trigger.

Forms of ANXIETY• Generalized anxiety disorder (300.02) — involves six months of persistent, excessive, and unrealistic worry.• Panic disorder (300.01) — may have a sudden onset causing apprehension, fear, or terror. Physical symptoms may include shortness of breath, heart palpitations, or chest pain, causing a person to think he or she is having a heart attack. If the panic attack is associated with agoraphobia (fear of places or situations where someone feels trapped or helpless), assign code 300.21. • Obsessive-compulsive disorder (300.3) — involves persistent, recurring thoughts/impulses (obsessions) and ritualistic actions (compulsions). This is different than obsessive-compulsive personality disorder (301.4).• Posttraumatic stress disorder (309.81) — occurs after a severe emotional or physical trauma and involves the feeling that the person is re-experiencing this traumatic event.

FORMS of ANXIETY• Social phobia (300.23) — a person may experience anxiety

when exposed to certain social events and desires to avoid the situation.

• Other phobia (300.2x) — anxiety when exposed to a specific object or situation and the desire to avoid it.• Alcohol-induced anxiety (291.89)• Drug-induced anxiety (292.89) • Separation anxiety (309.21) — occurs when a child is separated from his or her parents.• Acute stress disorder (308.3) — includes similar symptoms to posttraumatic stress disorder but occurs immediately after a traumatic event.

ANXIETY WITH DEPRESSION ICD-9

A diagnosis of anxiety is usually made with a physical examination and psychological evaluations.

Anxiety may be associated with depression. If both are documented by a provider, assign codes 311 and 300.00. However, if the provider links the two conditions, such as “depression with anxiety,” then code 300.4, Dysthymic disorder, may be assigned (AHA Coding Clinic for ICD-9-CM, 2001, third quarter, page 6).

ANXIETY IN ICD-10

• Anxiety is classified to ICD-10-CM category F41 and is similar in structure in ICD-10-CM as in ICD-9-CM; one difference is anxiety with depression. Two codes are available depending on severity: F34.1, Persistent anxiety depression, and F41.8, Anxiety depression (mild or not persistent).

• Dysthymic disorder also is classified to code F34.1 and includes depressive neurosis, depressive personality disorder, dysthymia, neurotic depression, and persistent anxiety depression.

Anxiety Fast Finders

Coding and Documenting Depression

In ICD-10-CM, coding for depression requires specific documentation as to:

• Type and Acuity.

The default for unspecified depression is major depressive disorder, single episode (F32.9), which includes depressive disorder not otherwise specified (NOS) and major depression NOS.

Physician education and coding inquiries for clarification will be needed to accurately document the type and acuity of depression.

This will avoid misrepresentation of a less severe disorder as a major one.

Depression Fast Finder

Pain

Medical knowledge related to pain and pain syndromes has led to new classifications and codes for the various types of pain.

Frequently reported codes for pain and pain syndromes are found in two ICD-10-CM chapters:• Chapter 6 – Diseases of the Nervous System• Chapter 13 – Diseases of the Musculoskeletal System and

Connective Tissue

Commonly Treated Pain Diagnoses Found in Chapter 6• Migraine and other headache syndromes (categories G43-G44

)

• Causalgia (complex regional pain syndrome II) (CRPS II) (G56.4-, G57.7-)

• Complex regional pain syndrome I (CRPS I) (G90.5-)

• Neuralgia and other nerve, nerve root and plexus disorders (categories G50-G59)

• Pain, not elsewhere classified (category G89)

Pain Disorders Related to Psychological FactorsICD-10

Assign code F45.41, for pain that is exclusively related to psychological disorders. This must be CLEARLY documented.

Do not assign a code from category G89 if there is documentation of psychological component for a patient with acute or chronic pain.

PAIN G89G89 – Pain not elsewhere classified may be used in conjunction with codes from other categories and chapters to provide more detail about acute or chronic pain and neoplasm-related pain.

A code from category G89 should not be assigned if the underlying diagnosis is known UNLESS the reason for the visit is pain management and NOT management for the underlying condition.

If the pain is not specified as acute or chronic, post-thoracotomy, post-procedural, or neoplasm related, DO NOT assign a code from G89

A code from G89 should not be assigned if the definitive diagnosis is known unless the reason for the visit is pain control or management and not management for the underlying condition.

G89

This category includes: • Central pain syndrome, • Acute pain not elsewhere classified, • Chronic pain not elsewhere classified, • Neoplasm related pain, and • Chronic pain syndrome.

G89 as the Primary Diagnosis

G89 is acceptable as the primary dx when:• Pain control or pain management is the reason

for the office visit. The underlying cause of the pain should be documented in the EMR and reported as additional diagnosis if known.

• Code first the G89 followed by the condition causing the pain.

Site Specific Pain CodesG89 may be used in conjunction with codes that identify the site of pain (including codes from chapter 18) if the category G89 provides additional information. For example if the code describes the site of pain but does not describe if it is acute or chronic, both codes can be assigned.Sequencing:Is dependent on the circumstances of the visit.• If the visit is for pain control or management. Assign G89 followed

by the code identifying the pain. E.g. Acute pain due to trauma, followed by M54.2, cervicalgia

• If the visit is for any other reason except pain control or management and a related definitive dx. has not been established or confirmed by another provider, assign the code for the specific site of pain first, followed by the appropriate code from category G89

Chronic PAIN

There is no time frame defining when pain becomes chronic.

Provider documentation should be used as the guide for assigning a code for chronic pain.

Chronic pain is classified to subcategory G89.2

Central Pain Syndrome(Chronic vs Central)

Central pain syndrome, G89.0 and Chronic pain syndrome, G89.4 are different than the term “chronic pain” and therefore codes should only be used when the provider has specifically documented this condition.

Pain Fast Finder

Migraine and Other Headache Syndromes

In ICD-10-CM, the various types of migraines are reported with codes in category G43.

All migraines must be documented as intractable or not intractable and with status migrainosus or without status migrainosus. Migraine with aura = classic, migraine without = common

Status migrainosus refers to a rare and severe type that can last 72 hours or longer. The pain and nausea are so intense that people who experience this type of headache often need to be hospitalized. Additionally, certain medications, or medication withdrawal can cause this type of migraine

Intractable migraine is a migraine type that has some of the common signs of simple headache in addition of vertigo. Changes in the inner ear are the main factor for this vertigo. It is responsible for your body balance. When this vertigo happens the stand or walk ability is changed.

Simple migraine type is a headache which occurs on of one side of our heads, and it is painful. Aura and visual disturbances may be occurred before this painful headache phase in this simple migraine and many other migraine forms such as intractable and ocular migraine ( it is also named as a vestibular, ocular, painless, eye, visual and silent migraine ).

Migraine and Other Headache Syndromes

Terms that describe intractable migraine include: • pharmacoresistant or pharmacologically

resistant, • treatment resistant, • refractory, and • poorly controlled.

Migraine and Other Headache Syndromes

Other headache syndromes are reported with codes from category G44 and include: cluster headaches, vascular headache not elsewhere classified, tension-type headaches, post-traumatic headaches, drug-induced headaches, as well as others.

Migraine and Other Headache Syndromes

Other headache syndromes are reported with codes from category G44 and include: • cluster headaches, • vascular headache not elsewhere

classified,• tension-type headaches, • post-traumatic headaches, • drug-induced headaches

Migraine Fast Finder

Abdominal Pain Documentation

There is a one to one crosswalk from ICD-9 (789.00) to ICD-10 (R10.9) for abdominal pain unspecified site and unspecified abdominal pain.

It is important for the provider to document the location of the pain.• Upper and lower abdomen (horizontal line about the level of the

umbilicus) • Right side upper and left side upper• Right upper and left side upper • Pelvic area (right and left)

Additionally, it is crucial that the provider document exactly what the findings are, if any, to accurately record the exact course of action for the condition presented or defined after study, as well as for the coding and billing process.

Abdominal Pain in EPIC

CausalgiaAccurate Documentation Required

Causalgia, also referred to as complex regional pain syndrome type II (CRPS II), is a type of neuropathic pain that occurs following a distinct nerve injury, usually to a peripheral nerve in an extremity.

Causalgia of the upper limb is reported with codes in subcategory G56.4-.

Causalgia of the lower limb is reported with codes from subcategory G57.7-.

Fifth characters for both the upper and lower limbs identify laterality as unspecified (0), right (1), left (2).

Complex Regional Pain Syndrome I (CRPS I)Complex regional pain syndrome I is the most common type of CRPS.

CRPS II (causalgia) it is a type of neuropathic pain that usually occurs following an injury to an extremity. However, in CRPS I there is no direct injury to a nerve.

It can occur following an illness or it can occur without any known cause.

CRPS I is reported with codes from subcategory G90.5. Codes are specific to the upper and/or lower limbs and laterality.

Detailed documentation is required.

Chapter 13 – Diseases of the Musculoskeletal

System and Connective Tissue Many pain conditions are a result of musculoskeletal or connective tissue disorders and diseases. Codes for these conditions are found in Chapter 13 of ICD-10-CM.

An example of pain classified in Chapter 13 is radiculopathy associated with disorders and diseases of the spine. These conditions are found in block M40-M54 –Dorsopathies.

Other conditions related to pain medicine that are classified in Chapter 13 include, cervicalgia, sciatica, low back pain with and without sciatica, thoracic spine pain, joint pain, muscle spasm, myalgia, and fibromyalgia

Documenting Underdosing

Underdosing. Underdosing is a new code in ICD-10. It identifies situations in which a patient has taken less of a medication that was prescribed by the provider. The medical condition or diagnosis is sequenced first, with the underdosing code listed as a secondary diagnosis.

“The additional code tells us why the patient isn’t taking their medication.”

Since this is new, many physicians will not be in the habit of documenting a patient’s reasons for underdosing in the record.

UnderdosingFor underdosing, assign the code from categories T36 – T50 found in Chapter 19. These codes require a 7th character extension to describe an initial encounter (A), subsequent encounter (D), or sequela encounter (S).

Underdosing codes must be identified in the following order:

• The medical condition is sequenced first. The first-listed code would be the event that is triggered or prolonged due to this circumstance.

• The underdosing code is listed as the secondary code assignment. Codes for underdosing should never be assigned as principal or first-listed codes.

• The additional code explains why the patient is not taking the medication(s). Financial hardships and age-related debilities are some examples of underdosing.

Example• A patient is prescribed the antibiotic tetracycline to treat a UTI

(urinary tract infection). The patient did not take the medication as prescribed, which resulted in pyelonephritis (kidney infection).

CODE:• N10 Acute tubulo-interstitial nephritis (The first-listed code would

be the event that is triggered or prolonged due to this circumstance.)

• T36.4x6A Underdosing of tetracyclines, initial encounter (The underdosing code would be the secondary code assignment)

Partnership

As stated earlier in this presentation there is clear correlation between what the provider documented and what is report by the coder.Open communication is essential between both the provider and the biller/coder to ensure the provider is being adequately compensated for their work effort!

Thank YOU

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References• Code It Right online news letter – March 2013• Online article by Audrey Howard RHIA – 3M consulting

Services• AHIMA – Online For the Record 10/8/2012• AAPC website: “Documentation will become critical with ICD-

10”• Towers, Adele L. “Clinical Documentation Improvement – A

physician Perspective: Insider Tips For Getting Physician Participation in CDI Programs.” Journal of AHIMA 84, no 7 (July 2013): 34-41

• HFMA Educational Report, “The right documentation Strategy: Improving Your Clinical and Financial Performance” June 2013