Following the global pandemic, healthcare facilities all over the world have suffered chaos and the loss of an adequate system in various sectors. The efficiency that has entailed in the regular measurement and analysis of different medical departments has led to decreased revenue and patient satisfaction. Even before the world was hit by COVID-19 and its multiple variants, around 80% of patients in the United States faced inadequate postoperative and persistent pain management services. With ICD 10 codes for pain management, the documentation for pain has been made easier, paving way for further improvement in pain management services.
What Are Pain Management Services?
Pain management specialists may provide pain management services in healthcare setups via at-home remedies, exercise, lifestyle changes, medications, procedures, counseling, and therapy. Pain management involves documentation for pain and devising a treatment plan, which involves the adoption of a singular approach or a combination of several approaches, to reduce or relieve pain.
You can see a pain management specialist for any sort or degree of pain you may be experiencing. The time till pain relief depends mostly on the cause of pain and the type and duration of treatment received.
ICD 10 Codes in Pain Management Services
One of the most frequent findings in healthcare systems that lack proper pain management is inefficient documentation for pain. During this process, ICD 10 codes for pain management are often wrongly entered or misinterpreted. A few of the most common ICD 10 codes used in pain management services include
Ankle / Foot
- Plantar fasciitis – M72.2
- Tarsal tunnel syndrome – G57.50
Back (Thoracic, Lumbar, and Sacral Spine)
- Low back pain or Lumbago – M54.50
- Lumbar herniated disc – M51.26
- Lumbar radiculopathy (radiculitis) – M54.16
- Lumbar spinal stenosis – M48.061
- Lumbar spondylosis without myelopathy – M47.817
- Lumbar sprain – S33.5XXA
- Thoracic Sprain – S23.3XXA
- Vertebral fracture (pathologic)
- Golfer’s elbow or medial epicondylitis – M77.0X
- Tennis elbow or Lateral Epicondylitis – M77.1X
Hand / Wrist
- Carpal tunnel syndrome – G56.0X
- Cubital tunnel syndrome or Ulnar neuropathy – G56.2X
Head / Face
- Headache or Occipital neuralgia – R51.9 , M54.81
Hip / Pelvis / Thigh
- Hip osteoarthritis – M16.0 , M16.1X
- Piriformis syndrome or mononeuritis – G57.0X
- Trochanteric bursitis or Gluteal / Ischial bursitis – M70.6X
- Knee osteoarthritis – M17.X
Neck (Cervical Spine)
- Cervical herniated disc without myelopathy – M50.2XX
- Cervical radiculopathy or Radiculitis – M54.1X
- Cervical spondylosis without myelopathy – M47.812
- Cervical spinal stenosis – M48.02
- Neck pain or Cervicalgia – M54.2
- Chronic pain syndrome – G89.4
- Peripheral neuropathy – G60.9
- Glenohumeral (shoulder) Osteoarthritis – M19.01X
- Subacromial bursitis – M75.5X
Repercussions of Poor Pain Management
Pain could be classified as postoperative, psychological, functional, inflammatory, or neuropathic. Inadequate management amongst any of the above-mentioned pain classifications is common in the U.S. and is widely associated with multiple negative consequences. All of these combined are known to adversely affect the patient’s scope of recovery and quality of life.
Inadequate management of acute or any degree of pain could result in chronic pain. Mismanagement as a result of irregular follow-ups or incorrect entries of ICD- 10 codes for pain management in postoperative pain results in chronic postoperative pain. This mismanagement could either be failing to follow up on the patient’s condition or failing to record an adequate dose of painkillers or sedatives for the patient.
Persistent pain could likely result in impairments in muscular function, immune function, and wound healing. It could also cause malfunction in:
- Cardiovascular system, leading to diseases such as coronary ischemia and myocardial infarction
- Pulmonary system, leading to diseases such as decreased vital capacity, hypoventilation, and pulmonary infection
- Gastrointestinal system, leading to diseases such as reduced motility, nausea, vomiting, and ileus
- Renal system, leading to diseases such as increased urinary retention, oliguria, and sphincter tone
The normal functioning of someone suffering from persistent pain is greatly affected. The impact of impairment is relative to the severity of pain of the patient. People who endure postoperative pain due to poor documentation and mismanagement are likely to show a significant decrease in their mental health and physical and social functioning. Many patients face interference with their sleep cycles, and hence experience altered emotional states and unusual mood swings, impairing their social life.
Prolonged Opioid Use
Incessant and poorly documented pain during a course of treatment or after surgery may include extreme dependency on opioids or analgesic medications if they are required in large doses or for prolonged periods. Although these medications show the best results in minimizing and controlling the pain effectively, their doses should be limited to prevent any short or long-term side effects. Prolonged opioid use may result in addiction, nausea, vomiting, respiratory depression, bowel dysfunction, etc. These not only prove to be a substantial burden on the quality of life but also show the record of consistently increased hospital costs and prolonged stays.
Effects on Quality Of Life
Poor documentation of pain regardless of the ICD 10 codes for pain management potentially impairs sleep and takes a toll on the patient’s physiological and psychological health. The patient may suffer from sudden weight loss, loss of appetite, demoralization, and bouts of anxiety.
Ways to Improve Documentation for Pain Management Services
The idea of improving documentation for pain management consists of assessing and reassessing interventions that aim to individualize care. The following means ensure effective documentation system for pain.
Adopting Electronic Means
Electronic medical records are the best way to improve documentation for pain management. With electronic records, little to no room is left for errors in data input and coding. The ICD 10 codes for pain management are entered, analyzed, and extracted correctly to further aid this process. Electronic medical records help doctors and pain management specialists to keep track of data.
Communication between the physicians, nurses, and the administrative department is essential to improve documentation for pain management. A medical examiner is required to engage with the patient in a friendly and welcoming manner to establish trust. This enables the patient to confide in his/her doctor completely about their medical condition or symptoms. With a thorough medical examination, healthcare facilities potentially reduce their chances of making errors in the documentation of pain management services.
For patients who are unable to communicate the intensity or location of pain, the doctors are advised to carry out behavioral and physiological assessments to make accurate conclusions and diagnoses. These include interpretation of behavioral changes, such as facial expressions, sounds of cries, tears, negative shifts in mood, and/or stiffness in limb movement.
An accurate assessment of pain should be documented comprehensively while preventing any errors in ICD 10 pain management coding and billing. This assessment likely includes pain history, location and radiation pattern of pain, and the pain intensity. In many cases, pain scales are used where the patient is asked to rate the intensity of their pain on a scale of 1-10.
Other methods of assessment include lengthy questionnaires, which cover a wide range of pain dynamics the patient is feeling. Some of these are sophisticated and include a body outline, where the patient is required to shade the area of pain. Others may be far simpler, including a numerical scale or verbal indicators.
The most common cause of patients receiving inadequate consultation or treatment for pain relief stems from improper documentation. In many cases, inaccurate entry of ICD 10 pain management codes in patients’ medical records and poor assessment of pain is the source of inappropriate dosage prescriptions and intervals. However, this can be changed by adopting effective strategies to ensure the correct entry of ICD 10 odes for pain management.
At Precision Hub, we explain to you how proper medical coding and billing can be ensured at your healthcare facility to prevent any loss of revenue. Check out our website where you can find RCM consultants, who work with you to deliver patient-centered care.