ICD-9 coding for Pain Control

by Steve Adams

Effective October 1, 2006, ICD-9-CM category 338 was created for pain. With the creation of the new codes in this section, guidelines related to these codes were also added to the ICD-9-CM Official Guidelines for Coding and Reporting – effective November 15, 2006

A review of these guidelines (section I. C. 6) is important for correct code assignment. Several established guidelines also provide guidance on the proper use of these codes. Examples of these established guidelines are:

  • Signs and symptoms—codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for  reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider (I. B. 6).
  • Conditions that are an integral part of a disease process—signs and symptoms that are integral to the disease process should not be assigned as additional codes, unless otherwise instructed by the classification (I. B. 7).


When the Pain Code is the Principal Diagnosis

Category 338 codes are acceptable as the principal diagnosis for reporting purposes in two instances:

  • When pain control or pain management is the reason for the admission or encounter; or
  • When the related definitive diagnosis has not been established (confirmed)

Take for example a patient who has a displaced lumbar intervertebral disc and acute back pain and presents for injection of steroid into the spinal canal. This encounter would be coded to 338.19 (Other acute pain) and 722.10 (Lumbar intervertebral disc without myelopathy).

Another example – an encounter for pain management for acute neck pain from trauma would be coded to 338.11 (Acute pain due to trauma) and 723.1 (Cervicalgia).

The Pain Codes

The following are the codes in category 338 – These are the primary codes used along with the site specific pain code when the primary reason for the admission or encounter is pain control:

Central Pain Syndrome:

  • 338.0, Central pain syndrome;
    • Dejerine-Roussy syndrome;
    • Myelopathic pain syndrome;
    • Thalamic pain syndrome (hyperesthetic);

Acute and Chronic Pain

Acute pain typically begins suddenly and is usually a sharp feeling. It can range from mild to severe and may last a few minutes or a few weeks or months. However, acute pain does not typically last longer than six months. It disappears when the pain’s underlying cause is identified and treated. Acute pain may be caused by surgery, fractured bones, dental work, burns or cuts, or labor/childbirth.

Unrelieved acute pain may lead to chronic pain, which may persist even though the underlying injury has healed. Common effects of chronic pain include tense muscles, limited mobility, lack of energy, change in appetite, depression, anger, or anxiety.

A code from subcategories 338.1 and 338.2 (acute and chronic pain) should not be assigned if the underlying (definitive) diagnosis is known, unless the reason for the encounter is pain control or management and not management of the underlying condition. It is very important that coding professionals review, understand, and apply this guideline so that these codes are not over utilized.

For example, a patient diagnosed with chronic abdominal pain due to chronic Cholelithiasis would be coded to 574.20, while a patient who is being treated with spinal cord stimulation because of chronic pain syndrome due to thoracic spondylosis with myelopathy would be coded to 338.4 and 721.41.


Postoperative Pain

Postoperative pain may be reported as the principal diagnosis when the reason for the encounter is postoperative pain control or management. It may be assigned as a secondary diagnosis code when the patient presents for outpatient surgery and develops an unusual or inordinate amount of postoperative pain. Post-thoracotomy pain can be classified as acute (338.12) or chronic (338.22). The default code for post-thoracotomy and other postoperative pain not stated as acute or chronic is to code the acute form.

Special note: Routine or expected postoperative pain immediately after surgery should not be coded, and the provider’s documentation should guide the coding of postoperative pain.

Acute Pain

  • 338.11, Acute pain due to trauma;
  • 338.12, Acute postthoracotomy pain;
    • Postthoracotomy pain not otherwise specified (NOS);
  • 338.18, Other acute postoperative pain;
    • Postoperative pain NOS;
  • 338.19, Other acute pain;

Chronic Pain

  • 338.21, Chronic pain due to trauma;
  • 338.22, Chronic postthoracotomy pain;
  • 338.28, Other chronic postoperative pain;
  • 338.29, Other chronic pain;

Neoplasm-Related Pain

Code 338.3 is used to classify pain related to, associated with, or due to a tumor or cancer whether primary or secondary. This code is used as the principal code when the admission or encounter is for pain control or pain management. In this case, the underlying neoplasm should be reported in addition. When the encounter is for management of the neoplasm and the pain is also documented, it is appropriate to assign code 338.3 as an additional diagnosis.

For example, a patient who was admitted for insertion of a pump for control of pain due to liver metastasis from a history of breast cancer would be coded to 338.3, 197.7, and V10.3. In another example, a patient is seen because of lower back pain; the patient has prostate cancer, and a bone scan shows metastasis to bones. The encounter would be coded to 198.5, 185, and 338.3.

  • 338.3, Neoplasm related pain (acute) (chronic);
    • Cancer-associated pain;
    • Pain due to malignancy (primary) (secondary);
    • Tumor-associated pain;

Chronic Pain Syndrome

The diagnosis of chronic pain syndrome is not the same as chronic pain. Assign the code for chronic pain syndrome only when that diagnosis has been documented by the physician.

338.4, Chronic pain syndrome


Steve Adams, CPC, PCS is a Senior Consultant for InGauge Healthcare Solutions, Inc., an InHealth company.   Contact him for consulting and educational services at steve.adams@ingaugehsi.com.  Efficiency in Practice is the free eNewsletter for medical practice managers who want to save time, money and reduce risk.  For more information and to access your FREE report, Patient Collections: It’s Make or Break for Many Practices, visit www.efficiencyinpractice.com

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