Q&A: Pain as a surgical complication of transplantations

Q: Consider a patient who is readmitted for postoperative pain control after a lung transplant two days prior. How would coders report this type of surgical complication in ICD-10-CM? In general, what are the guidelines for coding pain as a surgical complication of transplantations?

A: Let’s review the general guidelines first. Coders must have documentation that states the complication is due to the transplant procedure and should only use codes for complications if the complication affects the function of the transplanted organ. If it's unclear, query the provider.

If postoperative pain is in fact associated with a specific postoperative complication, list first a code from ICD-10-CM Chapter 19 for the complication (code from category T86.- for complications of transplanted organs and tissue), then list a pain code from category G89.- to identify whether the complication is acute or chronic. If postoperative pain is not specified as acute or chronic, coders should use the code for acute. This is one of the rare occasions when we can assume something in coding.

Now if you have had surgery, you know that it hurts when it is done, but that’s to be expected. We are not talking about coding pain that is routine or expected postoperative pain immediately after the surgery. If it is much worse than expected or it lasts longer than immediately after the surgery, then that is when the pain should be coded. Do not assume any condition that occurs after medical care or surgery is a complication unless otherwise instructed by the guidelines.

As for the scenario, it is not noted that the lung transplant is functioning improperly, so since the patient was admitted for the pain, the pain code should be listed first as the primary diagnosis. In the 2025 ICD-10-CM Alphabetic Index, find “pain, postoperative” or “pain, postprocedural” in order to report the pain. Both pathways refer to code G89.18, Other acute postprocedural pain. To tell the whole story, coders also need to code for the history of the lung transplant since the transplant is responsible for the pain.  “History, personal, surgery, transplant” in the Alphabetic Index refers coders to the main term “transplant.” Finding “transplant, lung(s)” then leads to the correct code of Z94.2, Lung transplant status).

Remember that a coder’s goal is to tell the patient’s story. The patient has postoperative pain. Why? Because they had a lung transplant. That is the story we are telling.

Editor’s note: This question was answered by Terry Tropin, MSHAI, RHIA, CCS-P, an AHIMA-approved ICD-10-CM/PCS trainer who taught medical terminology and medical coding at Montgomery College in Maryland for more than two decades, during the HCPro webinar, “ICD-10-CM Coding for Surgical Complications.” This Q&A originally appeared in JustCoding.