OBJECTIVES

Understand how pain is measured. List the current treatments for pain. Identify pain codes in ICD-9-CM. Define the different pain groups.

Measurement of Pain

Each person has a different response to pain. Even at different times and under different circumstances one may feel varying levels of pain with the same condition. Communication with the health care team and family is necessary for best pain control. The use of a consistent pain scale helps to best communicate the level of pain a patient experiences.

Wong/Baker Face Scale

Numeric ScaleNumeric Scale

It is important to let the healthcare team know It is important to let the healthcare team know about your pain. A helpful way is to keep a journal. about your pain. A helpful way is to keep a journal. It is important to tell your healthcare team : It is important to tell your healthcare team : •Where the pain is? Where the pain is?

•What it feels like sharp, dull, achy, and tinglyWhat it feels like sharp, dull, achy, and tingly

•How long the pain lasts How long the pain lasts

•What helps the pain, what makes it worse What helps the pain, what makes it worse

•What medications you are taking and how much What medications you are taking and how much and how long they helpand how long they help

Medications Common pain relievers – Non-aspirin pain relievers such as acetaminophen (Tylenol®) can relieve

headaches and minor pain but do not reduce swelling. They are sometimes used in combination with other drugs to provide greater pain relief.

Anti-inflammatory drugs - Aspirin (Anacin®, Bayer®), coated or buffered aspirin (Ascripton®, Bufferin®) and aspirin with acetaminophen (Excedrin®) may be used to reduce swelling and irritation as well as to relieve pain. There also are non-steroidal anti-inflammatory drugs (NSAIDs, commonly called "N-sayeds") such as ibuprofen (Advil®, Motrin®) and naproxen (Aleve®). Anti-inflammatory drugs are used to relieve pain, inflammation and fever. There also are steroidal drugs (like cortisol and prednisone), available only by prescription, that are used to treat more serious inflammatory conditions such as chronic arthritis.

Opioid pain medications - Morphine-like drugs called opioids are prescribed to treat acute pain or cancer pain. They are occasionally used for certain chronic, non cancer pain as well.

Anti-depressants - These drugs were originally used only to treat depression. Studies now show, however, that they also can relieve certain pain. Available only by prescription, they often are used to help you sleep better at night.

Anti-seizure medicines - These medications are used to relieve what some patients describe as "shooting" pain by decreasing abnormal painful sensations caused by damaged nerves.

Other medicines - The doctor may also prescribe other types of medication that will be helpful for your specific pain problems. In addition, medications that counteract the side effects of opioids or treat the anxiety and depression associated with pain may also be prescribed.

Other TreatmentsMedication alone may not be enough to manage certain kinds of pain. Some medicines Medication alone may not be enough to manage certain kinds of pain. Some medicines are more effective in fighting pain when they are combined with other methods of are more effective in fighting pain when they are combined with other methods of treatment. In some cases, the patient's pain condition may respond to treatment instead treatment. In some cases, the patient's pain condition may respond to treatment instead of medication. In fact, for some patients, certain therapies may eventually replace the of medication. In fact, for some patients, certain therapies may eventually replace the need for taking any pain medicine, or less of it, over time. Here are just some of the need for taking any pain medicine, or less of it, over time. Here are just some of the available treatments being used successfully to treat pain patients.available treatments being used successfully to treat pain patients.

Injection treatments - Local anesthetics (such as Novocain®), with or without cortisone-like medicines, can be injected around nerve roots and into muscles or joints. These medicines reduce swelling, irritation, muscle spasms and abnormal nerve activity that can cause pain.

Nerve blocks - Often a group of nerves, called a plexus or ganglion, that causes pain to a specific organ or body region can be blocked with local anesthetics. If successful, another solution that numbs the nerves can then be injected.

Physical and aquatic therapy - The physiatrist or physical therapist may suggest an exercise program tailored for you that will increase your daily functioning and decrease your pain. Other treatments may include whirlpool therapy, ultrasound and deep-muscle massage.

Electrical stimulation - Transcutaneous electrical nerve stimulation (TENS) is the most common form of electrical stimulation used in pain management. It is not painful and does not require needles or medicine. TENS consists of a small, battery-operated device that can diminish pain by stimulating nerve fibers through the skin.

Acupuncture - This ancient Chinese practice uses very thin needles at very specific points on the skin to treat disease and pain. Practitioners of acupuncture undergo specialized training in these techniques and may offer this treatment for certain painful conditions.

Psychological support - Many patients who are in pain feel the emotional effects of suffering along with the physical aspects of pain. These may include feelings of anger, sadness, hopelessness or despair. In addition, pain can alter one's personality, disrupt sleep, interfere with work and relationships and often have a profound effect on family members. Support and counseling from a psychiatrist or psychologist, combined with a comprehensive pain treatment program, may be needed to help you manage your condition. These trained professionals also can teach you additional self-help therapies such as relaxation training or biofeedback to relieve pain, lessen muscle spasms and reduce stress.

Surgery - When necessary, surgical treatment may be recommended. In rare instances when severe pain has not responded to other treatments and procedures, surgery on certain nerves can be done to give the patient some relief and allow them to resume near-normal activities. Usually all other avenues of treatment are tried before surgery is considered.

PAIN CODES

Why New Pain Codes?

Historically pain codes were relegated to Chapter 16 for Symptoms, Signs, and Ill-defined Conditions.1

Remember the original use of ICD-9-CM is to report morbidity and mortality. The pain codes assist in identifying areas of improvement in medicine, research and therapies.

From a reimbursement standpoint, the immediate impact of the pain code changes from one chapter to another has also included DRG changes.

The ICD-9-CM ClassificationsThe ICD-9-CM Classifications

Defining the different pain groupDefining the different pain groupss

IN THE ICD-9-CM BOOK..

The pain codes are located in Chapter 6, The Nervous System and Sense Organs

They are located in category 338 338

338.0-338.4338.0-338.4- Essentially the category is broken down into central pain syndrome, acute pain, chronic pain, neoplasm related pain, and chronic pain syndrome.

Dissecting the Codes

Code 338.0338.0 is used for Central pain Central pain syndromesyndrome

Code 338.1X- 338.1X- Acute painAcute pain

338.11338.11 Acute pain due to trauma

338.12338.12 Acute post-thoracotomy pain

338.18338.18 Other acute postoperative pain

338.19338.19 Other acute pain

Code 338.2X –338.2X –Chronic painChronic pain

338.21338.21- Chronic pain due to trauma

338.22338.22 Chronic post-thoracotomy pain

338.28338.28 Other chronic postoperative pain

338.29338.29 Other chronic pain

Code 338.3338.3 Neoplasm related painNeoplasm related pain (acute) (chronic)- Cancer associated pain, pain due to malignancy (primary) (secondary), tumor associated.

Code 338.4338.4 Chronic pain syndromeChronic pain syndrome

Chronic pain associated with significant psychosocial

dysfunction.

Central Pain Syndrome 338.0

Central pain syndrome is a neurological condition caused by dysfunction that specifically affects the central nervous system (CNS) which includes the brain, brainstem, and spinal cord.

The disorder occurs in people who have-or who have experienced strokes, multiple sclerosis, limb amputations, brain injuries, or spinal cord injuries and may develop months or years after injury or damage to the CNS.

Characterized by a mixture of pain sensations, the most prominent being a constant burning. Pain also increases in the presence of temperature changes, most often cold temperatures. A loss of sensation can occur in affected areas, most prominently on distant parts of the body, such as hands and feet. There may be brief, intolerable bursts of sharp pain on occasion.

TreatmentTreatment

Pain medication often provide little or no relief for thos affected by central pain syndrome. Doctors recommend people with the condition be sedated and the nervous system kept quiet and as free from stress as possible.

Acute Pain 338.11-338.19

Acute pain may be mild and last just a moment. It also can be severe and last for weeks or months, as does pain from a burn, pulled muscle, or broken bone.

Acute pain has a distinct beginning and end. The cause of acute pain is known and, as you heal, the pain will lessen and finally go away.

Acute pain usually starts suddenly, may be sharp, and often triggers visible bodily reactions such as sweating, an elevated blood pressure, and more. Acute pain is generally a signal of rapid-onset injury to the body and it resolves when pain relief is given or the injury is treated.

Pain should be considered the fifth vital sign, along with respiration, pulse, blood pressure, and core temperature.

Most of the time medication and other treatment can greatly relieve acute pain. Pain management is an important part of effective total care.

Incidence:

Muscle pain, one of the most common types of acute pain, affects 53 percent of Americans.

Lower back pain is the most common form of acute pain and is the fifth most common cause for all physician visits. It is responsible for direct health care expenditures of more than $20 billion annually.

Causes:

Acute pain is triggered by tissue damage such as a skin burn, muscle pain, or a broken bone. It’s the type of pain that generally accompanies an illness, an injury, or surgery.

Acute pain can manifest in just about any part of the body.

Chronic pain 338.21-338.29 Chronic pain lasts. Pain is considered chronic when it continues beyond the

usual recovery period for an injury or an illness. It may be continuous or come and go.

Chronic pain, sometimes called persistent pain, can be very stressful for both the body and the soul and requires careful, ongoing attention to be appropriately treated.

Chronic pain is often intractable, as the cause of pain cannot be removed or treated.

Chronic pain is the number one cause of adult disability in the United States.

Chronic pain can touch nearly every part of a person’s daily life. It also has an impact on the family and, because of its economic and social consequences, it affects us all.

Chronic pain can be a source of frustration for the health care professionals who seek to provide care and assistance.

Incidence:

The American Chronic Pain Association (ACPA) estimates that one in three Americans (approximately 50 million

people) suffers from some type of chronic pain

Causes: _ Lower back problems, arthritis, cancer, RSDS, repetitive stress injuries, shingles, headaches, and fibromyalgia are the most common sources of chronic pain.

_ Others include diabetic neuropathy, phantom limb sensation, and other neurological conditions.

Neoplasm pain- 338.3

Not everyone who has cancer experiences pain; those who do may not have it all the time.

Ongoing cancer pain can be successfully treated in about 95 percent of people with cancer with the drug and non-drug therapies that are currently available.

Along with ongoing cancer pain, sometimes people have acute flares of pain when not all pain is controlled by the medication or therapy. This pain, usually called breakthrough pain, can also be controlled by additional medications.

Cancer patients often downplay their pain to doctors for fear that their pain means that their cancer is getting worse or that they will be thought to be complainers.

In almost every aspect of cancer treatment—surgery, chemotherapy or radiation—cancer patients follow the lead of their doctors. But when it comes to pain, patients need to assert themselves and be open about the degree of pain they are experiencing.

Incidence:

Approximately 30 to 40 percent of Americans diagnosed with cancer experience moderate to severe pain, with 90 percent of people who have a more advanced diagnosis of cancer experiencing significant amount of pain.

Sixty to 80 percent of all cancer patients with bone metastases feel pain.

Causes:

Most cancer pain is caused by the effects of cancer itself, side effects of treatment, compression on bones, nerves or body organs, poor blood circulation, blockage of an organ, metastasis, infection, or inflammation.

Chronic Pain Syndrome-338.4

SYMPTOMS:

Reduced activityReduced activity

Impaired sleepImpaired sleep

DepressionDepression

Suicidal ideationSuicidal ideation

Social withdrawalSocial withdrawal

Irritability and FatigueIrritability and Fatigue

Strong somatic focusStrong somatic focus

Memory and cognitive Memory and cognitive impairmentimpairment

Misbehavior by children in Misbehavior by children in the homethe home

Less interest in sexLess interest in sex

•Relationship problems Relationship problems •Pain behaviors Pain behaviors •HelplessnessHelplessness•HopelessnessHopelessness•Alcohol abuseAlcohol abuse•Medication abuseMedication abuse•GuiltGuilt•AnxietyAnxiety•Poor self-esteemPoor self-esteem•Loss of employmentLoss of employment•KinesiophobiaKinesiophobia

75% of the 10% (or more) of individuals who develop chronic pain lead relatively normal lives, although they may not return to full-time employment.

About 25% of those with chronic pain develop Chronic Pain Syndromes

Likelihood of developing a Chronic Pain Syndrome is unrelated to pain intensity.

Psychological variables (e.g., depression; somatic focus) and self-perceived disability consistently have been found to be the most accurate predictors of subsequent pain syndrome development

References

For the Record, ”What a Pain”, Judy Sturgeon, CCS, Vol. 18 No. 25 p.8, December 11, 2006

For the Record, “Coding for Pain” Audrey Howard, RHIA of 3M Consulting Services, Vol. 10, No. 11, p 38, May 29, 2007

ICD-9-CM Official Guidelines for Coding and Reporting, Coding Clinic, Fourth Quarter 2007

Wong-Baker FACES Pain Rating Scale, From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc.

CancerSymptoms.org

American Society of Anesthesiologist

American Chronic Pain Association

Epping-Jordan, J.E., Wahlgren, D.R., Williams, R.A., et al. (1998). Transition to chronic pain in men with low back pain: Predictive relationships among pain intensity, disability, and depressive symptoms. Health Psychology, 17, 421-427.

Fricton, O.T. (1996). Predictors of outcome for treatment of temporomandibular disorders. Journal of Oralfacial Pain, 10, 54-65.

CHRONIC PAIN SYNDROMES VS. CHRONIC PAIN, Michael E. Clark, Ph.D.Clinical Director, Chronic Pain Rehabilitation Program , James A. Haley Veterans Hospital