ICD-9-CM Official Guidelines for Coding and Reporting - Office of ...

principal or first-listed diagnosis in accordance with
Section I.C.6.a.1.a above.
(c)
(d)
Postoperative pain as principal or first-listed
diagnosis
Postoperative pain may be reported as the principal or
first-listed diagnosis when the stated reason for the
admission/encounter is documented as postoperative
pain control/management.
Postoperative pain as secondary diagnosis
Postoperative pain may be reported as a secondary
diagnosis code when a patient presents for outpatient
surgery and develops an unusual or inordinate amount
of postoperative pain.
The provider’s documentation should be used to guide
the coding of postoperative pain, as well as Section III.
Reporting Additional Diagnoses and Section IV.
Diagnostic Coding and Reporting in the Outpatient
Setting.
See Section II.I.2 for information on sequencing of
diagnoses for patients admitted to hospital inpatient
care following post-operative observation.
See Section II.J for information on sequencing of
diagnoses for patients admitted to hospital inpatient
care from outpatient surgery.
See Section IV.A.2 for information on sequencing of
diagnoses for patients admitted for observation.
4) Chronic pain
Chronic pain is classified to subcategory 338.2. There is
no time frame defining when pain becomes chronic
pain. The provider’s documentation should be used to
guide use of these codes.
5) Neoplasm Related Pain
Code 338.3 is assigned to pain documented as being
related, associated or due to cancer, primary or
secondary malignancy, or tumor. This code is assigned
regardless of whether the pain is acute or chronic.
ICD-9-CM Official Guidelines for Coding and Reporting
Effective October 1, 2008
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