BWC Recognition of ICD-10-CM Codes for “Pain”

 

Introduction

 

Authorization, delivery, and payment of medical services and other benefits in the Ohio Workers’ Compensation System is dependent on a medical diagnosis (condition) being recognized as an “allowed” condition in a claim.  Once a condition is recognized as “allowed”, BWC assigns the condition a code based on the International Classification of Diseases, 10^th Revision, Clinical Modification (ICD-10-CM).  This classification system and process is commonly used in United States medical industry to reflect diagnoses and process material information for a variety of means including, but not limited to authorization of services, payment of bills, research purposes, etc.  The codes in the system are updated annually with addition, modification, and deletion of codes as appropriate.

 

Through the years BWC has recognized most but not all codes listed in ICD-10CM.  Several codes (and the associated medical conditions/diagnoses) are not related to work injuries or occupational diseases.  Also, BWC has required that a code be descriptive of the condition to the extent of representing some degree of linkage of the code to a work injury.  Codes describing symptoms such as pain, nausea, vomiting, fever, etc. are not recognized.  For example, an individual who sustains low back pain while lifting on the job may describe “back ache or back pain”.  These descriptors of symptoms are not recognized by BWC, but the more descriptive diagnosis of “sprain/strain lumbar spine” is recognized.  The treatment of the diagnosis would also include treatment of the symptoms in the vast majority of claims.

 

In recent years the medical community has had increased focus on the treatment of pain and particularly chronic pain.  In response, in 2002 BWC recognized several ICD-- diagnostic codes to appropriately represent chronic pain as allowed conditions.  These codes include the following which may be currently allowed in a claim:

 

• M25.5* and M79.64* category codes pain in joint (fifth and sixth characters based on site and laterality)
• F45.42 pain disorder associated with both psychological and general medical condition

• G90.511 (right upper limb), G90.512 (left upper limb), and G90.513 (bilateral upper limbs)            Reflex Sympathetic Dystrophy (RSD), upper limb [Complex regional pain syndrome I of upper limb (CRPS I)]
• G90.521 (right lower limb), G90.522 (left lower limb), and G90.523 (bilateral lower limbs) Reflex Sympathetic Dystrophy (RSD), lower limb [Complex regional pain syndrome I of lower limb (CRPS I)]
• G90.59 Reflex Sympathetic Dystrophy (RSD) of other specified site
• G56.41 (right upper limb), G56.42 (left upper limb), and G56.43 (bilateral upper limbs) Causalgia of upper limb [Complex regional pain syndrome II of upper limb (CRPS II)]
• G57.71 (right lower limb), G57.72 (left lower limb), and G57.73 (bilateral lower limbs) Causalgia of lower limb [Complex regional pain syndrome II of lower limb (CRPS II)]
• M53.9  Chronic lumbosacral sprain/strain (claim already allowed for lumbar/lumbosacral sprain/strain)
• M96.1  Postlaminectomy syndrome
• M79.7  Fibromyalgia

 

The 2017 version of ICD-10-CM has included an additional diagnostic code (G89 category) specific to pain.[1]  This document provides information as to how BWC will recognize or not recognize these codes and the rationale for these decisions.  The last part of the document will provide the diagnostic criteria required to support the codes recognized by BWC. 

 

 

ICD-10-CM (2017 Version) “PAIN (G89)” Codes

 

It should be realized that the term “chronic” is not defined in ICD-10-CM.  For BWC purposes, ongoing pain symptoms of at least 12 months duration post completion of conservative care or last definitive surgical procedure (laminectomy, fusion, etc.) provided there has been ongoing medical care and attempts to identify and treat the source of the pain by the injured worker will be considered as major criteria for any of the BWC recognized chronic pain diagnoses.

 

“G89 Pain, not elsewhere classified” instructs the user to “use additional code to identify: pain associated with psychological factors (F45.42)”. This code excludes generalized pain (R52) and “localized pain, unspecific type” which is coded to pain by site.  It also excludes pain disorder extensively attributed to psychological factors (F45.41).  Since this code is nonspecific and requires an additional code, BWC does not recognize this code.

 

“G89.0 Central Pain Syndrome” includes Dejerine-Roussy syndrome, myelopathic pain syndrome, and thalamic pain syndrome (hyperesthetic).  These are not common pain syndromes seen in workers’ compensation and BWC does not recognize this code.

 

“G89.1* Acute Pain” includes fifth character designations for “G89.11 acute pain due to trauma”, “G89.12 acute post-thoracotomy pain”, “G89.18 other acute postoperative pain”.  As noted all of these codes describe acute pain whose treatment should be reasonably covered by other diagnoses or the authorization of procedures to treat the diagnoses.  Therefore, these codes are not recognized by BWC.

 

“G89.2 Chronic Pain” specifically excludes “G57.7* causalgia”, “G57.71 (right), G57.72 (left), and G57.73 (bilateral) causalgia lower limb”, “G56.41 (right), G56.42 (left), and G56.43 (bilateral) causalgia upper limb”, “G89.4 chronic pain syndrome”, “M79.7 myofascial pain syndrome”, “G89.3 neoplasm related chronic pain”, and “G90.5* reflex sympathetic dystrophy (fifth and sixth characters based on site and laterality)”.  G89.2 “Chronic pain” itself lacks specificity or infer a causal relationship to work injury or treatment to work injury. Therefore, code G89.2 is not recognized by BWC. 

 

The other codes under G89.2 which have a fifth character are recognized by BWC and include the following codes which can be allowed when the condition and medical document meet diagnostic criteria.  These codes include “G89.21 chronic pain due to trauma”, “G89.22 chronic post-thoracotomy pain”, “G89.28 other chronic postoperative pain” and “G89.29 other chronic pain”.  To enhance the specificity of the code “G89.29 other chronic pain” and identification of the body part involved in the allowance, BWC will indicate the body part in the narrative for the code.  For example, an allowance for chronic low back pain that meets claim allowance criteria may be designated by BWC as “G89.29 other chronic pain – lumbar region”.  For the most part, this code will be reserved for those claims meeting the criteria for chronic pain in which there have been no operative procedures or no other code for chronic pain is appropriate.

 

“G89.3 Neoplasm related pain (acute) (chronic)” described as cancer associated pain, pain due to malignancy either primary or secondary, or tumor associated pain will be recognized by BWC when the claim has a specific neoplasm allowed in the claim and the condition meets other criteria for claim allowance.

 

“G89.4 Chronic pain syndrome” is described as chronic pain associated with significant psychosocial dysfunction.  Since this code is no more specific than “G89.2 Chronic pain” and by description has “significant psychosocial dysfunction” which in most cases should require psychological/psychiatric treatment, BWC will not recognize this code.  However, individuals with these findings should/may be considered appropriate for allowances of one of the other chronic pain codes combined with “F45.42 Pain disorder associated with both psychological and general medical condition” or a more specific psychiatric code such as “F32* major depressive disorder, single episode”.

 

“F45.41 Psychogenic pain, site unspecified” (described as “Pain Disorder Associated with Psychological Factors” in DSM-IV-TR[2]) is to be used when psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain.  General medical conditions play no role or a minimal role in the onset or maintenance of the pain.  Since the role of the medical condition is minimal, it would be difficult to link the psychological factors to the work injury.  Therefore, this condition will not be recognized by BWC as it relates to chronic pain conditions. 

 

In addition to these ICD-10 Codes for G89, the 2017 version of ICD-10-CM has “R52 Generalized pain” for pain Not Otherwise Specified.  Since this code is primarily a symptom code that is nonspecific and since the codes described above are more specific, BWC does not recognize this code.

 

As a result of these newer codes being recognized by BWC, “M53.9

chronic lumbosacral sprain/strain” when the claim already has an allowance for lumbar/lumbosacral sprain/strain will no longer be utilized since these claims will now be allowed for “G89.29 other chronic pain” with BWC staff inserting the description of the body region affected.

 

 

ICD-10-CM (2017 Version) “PAIN (G89)” Codes Recognized by BWC

 

In summary, the following codes will be recognized by BWC to represent allowances for conditions primarily manifest by chronic pain when allowance criteria are met:

 

    Previously recognized:

• M25.5* and M79.64*   pain in joint (fifth and sixth character of code identifies specific body part and laterality)
• F45.42 other pain disorder associated with both psychological and general medical condition G90.511 (right), G90.512 (left), and G90.513 (bilateral) Reflex Sympathetic Dystrophy (RSD), upper limb

• G90.521 (right), G90.522 (left), and G90.523 (bilateral) Reflex Sympathetic Dystrophy (RSD), lower limb
• M96.1  Post-laminectomy syndrome
• M79.7  Fibromyalgia

 

    Recognized as a result of ICD-10-CM (2017 Version):

• G89.21            Chronic pain due to trauma
• G89.22            Chronic post-thoracotomy pain
• G89.28            Other chronic post-operative pain
• G89.29            Other chronic pain
• G89.3              Neoplasm related pain (acute) (chronic)

 

(Note:  BWC Staff will indicate in the code descriptor the body part/region considered responsible/involved in the chronic pain.)

(Note:  While BWC does not recognize “G89.4 chronic pain syndrome” described as chronic pain associated with significant psychosocial dysfunction, any of the codes listed above may be additionally allowed for “F45.42” or another psychiatric ICD-10 Code if the allowance criteria are met.)

 

    No longer recognized by BWC in future claims:

• M53.9  Chronic lumbosacral sprain/strain (claim already allowed for lumbar/lumbosacral sprain/strain)

Pain in Joint (Chronic) 

ICD-10 Code: M25.5* and M79.64* (fifth and sixth characters identify body part and laterality)

 

 

Definition:     

Ongoing pain symptoms of at least 12 months duration post completion of conservative treatment or last definitive surgical procedure provided medical records indicate there has been ongoing medical care and attempts to identify and treat the source of pain.  Such attempts should include appropriate diagnostic studies and consultations.

 

 

Note:  This diagnosis is a secondary diagnosis of ongoing symptoms after completion of treatment in an individual who is significantly limited due to pain in a joint allowed in the claim.  It requires a primary diagnosis recognized as allowed for the specific joint.  It should not be used when a more specific and appropriate diagnosis is available to explain symptoms such as osteoarthritis, chondromalacia patellae, or adhesive capsulitis. Injured worker should be at maximum medical improvement in relation to the allowed condition of the joint.

 

 

Subjective:

 

• Symptoms of pain of varying nature, intensity, and character localized to joint with primary allowed condition.
• Treatment must be shown to have been present for at least 12 months following completion of conservative or last surgical treatment.
• May have other symptoms such as but not limited to joint swelling, buckling, decreased motion, or instability.  Symptoms including pain should not involve multiple sites such as polyarthralgia, fibromyalgia, or systemic connective tissue diseases.

 

 

Objective:

 

• None

 

 

Diagnostic Tests:

 

• Diagnostic studies and medical records show absence of other appropriate diagnoses to account for painful condition including but not limited to osteoarthritis, recurrent injury such as torn meniscus, tendonitis, adhesive capsulitis, or degenerative condition of cartilage.  Medical records should document diagnostic studies and/or consults to try to determine the source of pain.

 

 

 

Chronic lumbosacral sprain/strain

ICD-10 Code: M53.9

(Note:  This code no longer used after April 1, 2007, as it is replaced by “G89.29 other chronic pain”.  Claims with this allowance prior to April 1, 2007, will continue to recognize this code in the claim allowance.)

 

Definition:     

 

Ongoing pain symptoms of the lumbosacral region of at least 12 months duration post completion of conservative treatment provided medical records indicate there has been ongoing medical care and attempts to identify and treat the source of pain.  Such attempts should include appropriate diagnostic studies and consultations.

 

 

Note:  This diagnosis is a secondary diagnosis of ongoing symptoms after completion of treatment in an individual whose activity is significantly limited due to pain.  It requires a primary diagnosis recognized as allowed such as lumbosacral sprain/strain and lack of invasive surgical intervention such as laminectomy, discectomy, or fusion.  It should not be used when a more specific and appropriate diagnosis is available to explain symptoms such as degenerative disc disease, spondylosis, or spondylolisthesis. Injured worker should be at maximum medical improvement in relation to the allowed condition of the lumbar spine.

 

 

Subjective:

 

• Symptoms of pain of varying nature, intensity, and character localized to low back with primary allowed condition having received conservative treatment and evaluation for more specific cause of pain such as herniated disc, etc.
• Treatment must be shown to have been present at least 12 months following completion of conservative treatment.
• May have other symptoms such as but not limited to leg pain, weakness, decreased spinal movement, etc. 
• Symptoms including pain should not involve multiple sites such as polyarthralgia, fibromyalgia, or systemic connective tissue diseases.

 

 

Objective:

 

• None specific. Diagnosis is for chronic symptom of pain.

 

 

Diagnostic Tests:

 

• Diagnostic studies and medical records show absence of other appropriate diagnoses to account for painful condition including but not limited to disc pathology, spondylosis, spondylolisthesis, degenerative disc disease, and degenerative osteoarthritis.

Post-laminectomy Syndrome (for all back levels)

ICD-10 Code: M96.1

 

Definition:     

 

Ongoing pain symptoms of at least 12 months duration post completion of definitive surgical procedure such as discectomy, laminectomy, fusion, etc. (Surgical procedure does not include epiduroscopy, epidural steroid injection, myelogram, or discograms.) provided medical records indicate that pain is primary factor limiting performance of activities and focus of medical care is toward controlling/relieving pain.  Medical records should document there has been ongoing medical care and attempts to identify and treat the source of pain.  Such attempts should include appropriate diagnostic studies and consultations.

 

Note:  This diagnosis is a secondary diagnosis of ongoing symptoms after completion of surgical treatment and rehabilitation in an individual who has undergone a surgical spinal procedure and is significantly limited due to pain.  It requires a primary diagnosis recognized as allowed such as lumbosacral sprain/strain and usually a secondary diagnosis to allow for the surgical procedure and documentation of invasive surgical intervention such as laminectomy, discectomy, or fusion. Many of these injured workers may have completed or may be eligible for multidisciplinary pain treatment program.  Injured worker should be at maximum medical improvement in relation to the allowed condition of the lumbar spine for which the individual underwent the procedure.

 

 

Subjective:

 

• Symptoms of pain of varying nature, intensity, and character localized to spine region with primary allowed condition having received surgical procedure, rehabilitation, and evaluation for more specific cause of pain such as recurrent herniated disc, etc. causing symptoms postoperatively.
• Treatment must be shown to have been present at least 12 months following completion of last surgical treatment.
• May have other symptoms such as but not limited to leg pain, weakness, decreased spinal movement, etc. 
• Symptoms including pain should not involve multiple sites such as polyarthralgia, fibromyalgia, or systemic connective tissue diseases.

 

 

Objective:

 

• None specific.  Diagnosis is for chronic symptom of pain.

 

 

Diagnostic Tests:

 

• Diagnostic studies and medical records show prior surgical procedure and absence of more specific diagnosis to explain painful condition such as recurrent herniated disc, etc.  Medical records should document diagnostic procedures and/or consultations to try to determine and treat the source of pain in the individual.

 

Chronic pain due to trauma

ICD-10 Code: G89.21 “chronic pain due to trauma”

(Note: BWC to indicate body part/region in narrative for code)

 

Definition:     

Ongoing pain symptoms of at least 12 months duration post completion of conservative treatment or last definitive surgical procedure provided medical records indicate the mechanism of injury involved a significant traumatic event.  Medical records must document that there has been ongoing medical care and attempts to identify and treat the source of pain.  Such attempts should include appropriate diagnostic studies and consultations as appropriate.

 

 

Note:  This diagnosis is a secondary diagnosis of ongoing symptoms after completion of treatment in an individual who sustained a significant traumatic injury and whose activity is significantly limited due to pain.  It should not be used when a more specific and appropriate diagnosis is available to explain symptoms such as osteoarthritis, reflex sympathetic dystrophy, or neuropathic pain.  Injured worker should be at maximum medical improvement in relation to the allowed condition(s) pertaining to the traumatic event.

 

 

Subjective:

 

• Symptoms of pain of varying nature, intensity, and character localized to body region of primary allowed condition that has received completion of planned treatment.
• Treatment must be shown to have been present at least 12 months following completion of conservative or last surgical treatment.
• May have other symptoms such as but not limited to joint swelling, buckling, decreased motion, or instability.  Symptoms including pain should not involve multiple sites such as polyarthralgia, fibromyalgia, or systemic connective tissue diseases.

 

 

Objective:

 

• None

 

 

Diagnostic Tests:

 

• Diagnostic studies and medical records show absence of other appropriate diagnoses to account for painful condition such as osteoarthritis, reflex sympathetic dystrophy, etc.

 

 

 

Chronic post-thoracotomy pain

ICD-10 Code: G89.22

 

Definition:     

 

Ongoing pain symptoms of at least 12 months duration post completion of thoracotomy for a recognized allowed condition in the claim. Medical records must indicate that pain is primary factor limiting performance of activities and focus of medical care is toward controlling/relieving pain.  Medical records should document there has been ongoing medical care and attempts to identify and treat the source of pain.  Such attempts should include appropriate diagnostic studies and consultations.

 

 

 

Note:  This diagnosis is a secondary diagnosis of ongoing symptoms after completion of a thoracotomy for an allowed condition in an individual who is significantly limited due to pain when the pain is believed to be the primary result of the thoracotomy.

 

 

Subjective:

 

• Symptoms of pain of varying nature, intensity, and character localized to the region of the thoracotomy despite the individual having received conservative treatment and evaluation for more specific cause of pain.
• Treatment must be shown to have been present for at least 12 months following completion of conservative or last surgical treatment.
• May have other symptoms.
• Symptoms including pain should not involve multiple sites such as polyarthralgia, fibromyalgia, or systemic connective tissue diseases.

 

 

Objective:

 

• None specific. Diagnosis is for chronic symptom of pain.

 

 

Diagnostic Tests:

 

• Diagnostic studies and medical records show absence of other appropriate diagnoses to account for painful condition such as primary pulmonary or cardiac etiology.

 

 

 

Other chronic post-operative pain

ICD-10 Code: G89.28

(Note: BWC to indicate body part/region in narrative for code)

 

 

Definition:     

 

Ongoing pain symptoms of at least 12 months duration post completion of a definitive surgical procedure other than thoracotomy (G89.22) or lumbar discectomy, laminectomy or fusion (M96.1) for a recognized allowed condition in the claim. Medical records must indicate that pain is primary factor limiting performance of activities and focus of medical care is toward controlling/relieving pain.  Medical records should document there has been ongoing medical care and attempts to identify and treat the source of pain.  Such attempts should include appropriate diagnostic studies and consultations.

 

 

Note:  This diagnosis is a secondary diagnosis of ongoing symptoms after completion of surgical treatment in an individual who has undergone a surgical procedure and is significantly limited due to pain believed to be the result of the procedure.

 

 

Subjective:

 

• Symptoms of pain of varying nature, intensity, and character localized to the body region of the primary allowed condition for which the surgical procedure was performed.
• Treatment must be shown to have been present at least 12 months following completion of the last surgical treatment.
• May have other symptoms such as but not limited to referred pain, weakness, decreased movement, etc. 
• Symptoms including pain should not involve multiple sites such as polyarthralgia, fibromyalgia, or systemic connective tissue diseases.

 

 

Objective:

 

• None specific. Diagnosis is for chronic symptom of pain.

 

 

Diagnostic Tests:

 

• Diagnostic studies and medical records show prior surgical procedure and absence of more specific diagnosis to explain painful condition such as recurrent herniated disc, RSD, osteoarthritis, etc.

 

 

 

 

Other chronic pain

ICD-10 Code: G89.29

(Note: BWC to indicate body part/region in narrative for code)

(Note: Use this code only if documentation does not meet G89.21, G89.22, and G89.28 which are more specific codes.)

 

Definition:     

Pain in body part/region requiring medical care for at least 12 months (no reactivation) after completion of conservative treatment for the primary allowed condition. Medical records must indicate that pain is primary factor limiting performance of activities and focus of medical care is toward controlling/relieving pain.  Medical records should document there has been ongoing medical care and attempts to identify and treat the source of pain.  Such attempts should include appropriate diagnostic studies and consultations.

 

 

Note:  This diagnosis is a secondary diagnosis of ongoing symptoms after completion of treatment in an individual who is significantly limited due to pain.  It requires a primary diagnosis recognized as allowed for the specific body part/region.  It should not be used when a more specific and appropriate diagnosis is available to explain symptoms such as osteoarthritis, reflex sympathetic dystrophy, etc. or a more specific chronic pain diagnosis such as chronic post-thoracotomy pain or post-laminectomy syndrome.

 

 

Subjective:

 

• Symptoms of pain of varying nature, intensity, and character localized to body part/region for the primary allowed condition that has received completion of conservative treatment.
• Treatment must be shown to have been present for at least 12 months following completion of conservative treatment directed at the allowed condition in the claim.
• Symptoms including pain should not involve multiple sites such as polyarthralgia, fibromyalgia, or systemic connective tissue diseases.

 

 

Objective:

 

• None

 

 

Diagnostic Tests:

 

• Diagnostic studies and medical records show absence of other appropriate diagnoses to account for painful condition including but not limited to osteoarthritis, reflex sympathetic dystrophy, etc.

 

 

 

Neoplasm related pain (acute) (chronic)

ICD-10 Code: G89.3

 

Definition:     

 

Pain in body part/region as a direct result of a neoplasm which is a recognized allowed condition in the claim.  Pain must significantly impact activity and requires ongoing medical treatment directed toward relief of pain.  Individual may or may not have had surgery, chemotherapy, radiation therapy or other treatment of the neoplasm.  No specific difference in the claim allowance regarding acute versus chronic duration of pain.

 

 

Note:  This diagnosis is a secondary diagnosis of ongoing pain symptoms attributed directly to a recognized allowed condition of neoplasm of a body part/region/organ system.

 

 

Subjective:

 

• Symptoms of pain of varying nature, intensity, and character attributed to a neoplasm that is recognized as an allowed condition in the claim.
• Treatment does not have specific time duration but optimally individual should have received some treatment focused to the neoplasm.
• May have other symptoms such as but not limited to, weakness, fatigue, decreased appetite, etc. 
• Symptoms including pain should not involve multiple sites such as polyarthralgia, fibromyalgia, or systemic connective tissue diseases.

 

 

Objective:

 

• None specific. Diagnosis is for chronic symptom of pain.

 

 

Diagnostic Tests:

 

• Diagnostic studies and medical records support the diagnosis of the neoplasm.

 

 

 

Pain Disorder Associated with Both Psychological Factors and a General Medical Condition

ICD-10 Code: F45.42

 

Definition:     

 

Chronic pain condition in which both psychological factors and a general medical condition are considered to be significant contributors to the disorder whether the psychological contribution contributes to the onset, severity, exacerbation, or maintenance of the pain Evaluation and treatment in most cases will require evaluation and treatment of the medical conditions believed to be causing pain and evaluation and treatment of the psychological factors.

 

Note:  This diagnosis is a secondary diagnosis or second diagnosis of an individual who is already recognized as having a chronic pain condition recognized by BWC.  This condition may be combined with an allowance of a chronic pain disorder to provide the equivalent of chronic pain syndrome.  In lieu of this diagnostic code, more specific psychiatric diagnostic codes (most commonly those of depression) may be appropriate and more specific.

 

Note:  BWC does not recognize ICD-10 Code “F45.41 Psychogenic pain, site unspecified” since this code is a primary mental health code and a medical condition has no or very minimal role.

 

 

 

Subjective:

 

• Symptoms of pain of whose onset, severity, or maintenance are believed to be significantly affected by psychological factors and a chronic medical pain condition.
• Individual must have a chronic pain allowance describing a general medical condition.

 

 

Objective:

 

• None specific. 

 

 

Diagnostic Tests:

 

• Since this condition is considered a mental disorder, a psychological/psychiatric independent medical evaluation must be performed as in any other request for a psychological/psychiatric allowance.