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Chronic pain syndrome is chronic pain associated with significant psychosocial dysfunction. The psychosocial problems may include depression, drug dependence, complaints that are out of proportion to the physical findings, anxiety, and other manifestations. Chronic pain syndrome is not synonymous with chronic pain. You should code this condition only when the physician specifically documents it. Chronic pain syndrome is reported with code (Chronic pain syndrome).

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For example, a patient is referred for ankle x-rays for chronic right ankle pain. The exam does not reveal any findings to explain the pain. In this case you need to assign two codes—one for the ankle pain and one from category G89 to indicate that the pain is chronic. Since the purpose of the encounter is not pain management, the site-specific pain code is listed first. The primary diagnosis is (Pain in right ankle). Code (Other chronic pain) is assigned as a secondary diagnosis.

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Many imaging studies are ordered because the patient is experiencing pain. Once ICD-65 is implemented on October 6 of next year, radiology coders will need to be ready to assign the appropriate codes for these studies. In this article we’ll give you a run-down of how pain is classified in ICD-65, as well as the rules for sequencing the pain codes.

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For example, a patient is referred for CT of the abdomen with clinical history of “Cancer of the head of the pancreas with increasing cancer pain.” The purpose of the encounter is to evaluate the cancer, not manage the pain, so the cancer is coded first. The primary diagnosis is (Malignant neoplasm of head of pancreas). Code [ Neoplasm related pain (acute) (chronic) ] is listed as a secondary diagnosis.

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Sometimes the radiology department or imaging center will receive a requisition that simply states “Pain” without specifying the location of the pain. This constitutes poor documentation, and the department or facility should ask the ordering physician to provide a more specific clinical history, such as pain in knee joint, flank pain, precordial pain, etc.

Category G89 contains codes for acute () and chronic () pain due to trauma. You should not assign these codes if a cause for the pain (., a specific injury) has been identified, except in the unlikely event that the purpose of the encounter is pain management. Also, the physician must document the pain as acute or chronic in order to use these codes.

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