Q&A: Documenting psychosocial reasons for reporting chronic pain syndrome in ICD-10-CM

Q: What does a provider need to document for ICD-10-CM code G89.4 (chronic pain syndrome) showing there is a psychosocial reason for the pain?

A: First, let me say that just because somebody might have a diagnosis of depression does not mean that they are significantly psychosocially dysfunctional.

The provider and coder should look beyond chronic pain. How is it affecting the patient from a psycho-social standpoint? Are they unable to work? Has it caused extreme anxiety… and socially has it caused problems with a marriage? We need to see documentation of exactly what that psychosocial dysfunction looks like.

You must also look beyond whether the patient is being treated for a mental health condition, such as depression or anxiety. I have had providers say, “All of my patients are depressed.”

Well, a lot of people in this world take an antidepressant or something for anxiety, but that doesn’t mean that person is psychosocially dysfunctional. So, we need to know what that dysfunction is specifically.

Editor’s note: This Q&A was originally published in JustCoding. Amy Turner, RN, BSN, MMHC, CPC, CHC, CHIAP, vice president of provider education and advisory services, Ventra Health in Dallas, Texas, answered this question during the 2023 Advanced Specialty Coding Virtual Summit. A version of this article was originally published in Part B News.