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Outpatient Facility Coding Alert

Reader Question:

Note Circumstances of Postop Pain Before Determining Dx Code

Question: A patient is seen by the physician two days following an ethmoidectomy. The patient complains of pain in and around the ethmoid sinus. What diagnosis code should I use to report this condition?

Arizona Subscriber

Answer: You’ll want to consider the circumstances surrounding the patient’s pain to guard against incorrectly reporting a diagnosis code such as J34.89 (Other specified disorders of nose and nasal sinuses).

Since this is a postoperative symptom, you should report the patient’s pain diagnosis accordingly. The 2019 ICD-10-CM guidelines instruct you to report a postoperative pain code from category G depending on whether the pain is related to a postoperative complication. Assuming the provider does not document a postoperative complication that can account for the patient’s pain, you should abide by the following guidelines in Section 1.C.6.b:

  • “Postoperative pain not associated with a specific postoperative complication is assigned to the appropriate postoperative pain code in category G89 (Pain, not elsewhere classified).”

However, before reporting a code under category G89, consider this additional guideline:

  • “Routine or expected postoperative pain immediately after surgery should not be coded.”

It’s up to your provider to appropriately document whether or not the patient is experiencing typical postoperative pain, or whether the pain is atypical for an ethmoidectomy procedure. Assuming the provider documents that the pain is atypical, you should report code G89.18 (Other acute postprocedural pain).