BWC Recognition of ICD-9-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, 9^th Revision, Clinical Modification (ICD-9-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-9-CM.  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-9-CM diagnostic codes to appropriately represent chronic pain as allowed conditions.  These codes include the following which may be currently allowed in a claim:

 

- 719.4                   pain in joint (fifth digit of code identifies specific body part)

- 307.89     other psychalgia or pain disorder associated with both psychological and general medical condition

- 337.21     Reflex Sympathetic Dystrophy (RSD), upper limb [Complex regional pain syndrome I of upper limb (CRPS I)]

- 337.22     Reflex Sympathetic Dystrophy (RSD), lower limb [Complex regional pain syndrome I of lower limb (CRPS I)]

- 337.29     Reflex Sympathetic Dystrophy (RSD) of other specified site

- 354.4                   Causalgia of upper limb [Complex regional pain

syndrome II of upper limb (CRPS II)]

- 355.71     Causalgia of lower limb limb [Complex regional pain

syndrome II of lower limb (CRPS II)]

- 724.6                   Chronic lumbosacral sprain/strain (claim already allowed for  lumbar/lumbosacral sprain/strain)

- 722.8                   Postlaminectomy syndrome

- 729.1                   Fibromyalgia

 

The 2007 version of ICD-9-CM has included an additional diagnostic code (338) 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.