2025 ICD-10-CM code G89.18
(Active) Effective Date: N/A Diseases of the nervous system - Other disorders of the nervous system 6 Feed
Other acute postprocedural pain. This code encompasses pain following any surgical procedure other than a thoracotomy, lasting less than three months.
Medical necessity for the treatment of post-procedural pain must be established. The documentation should support the severity of the pain and its impact on the patient's function. The chosen treatment modality should be justified based on the individual patient's needs and clinical presentation.
Clinicians diagnose this condition based on the patient's surgical history, presented signs and symptoms, and a physical examination. Diagnostic studies such as blood tests (CBC), X-rays, CT scans, or ultrasounds of the painful area may be used. Treatment for other acute postprocedural pain may include over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) for mild to moderate pain or prescription opioids for more severe cases.
In simple words: This code describes severe pain that can occur after surgery (other than heart surgery), and lasts for less than three months.The pain might be from the incision, deeper tissues, or even your throat if you had a breathing tube.
Other acute postprocedural pain refers to severe pain after any surgical procedure other than a thoracotomy, lasting less than three months.This pain may arise from inflammation or the severing of bones, joints, muscles, or nerves during the procedure. Symptoms can include severe pain, numbness, and sensory loss at or deep to the incision site. Throat pain following general anesthesia or intubation may also be included.Pain due to surgical complications can also be considered. Diagnosis is based on surgical history, symptoms, physical examination, and may be aided by blood tests, X-rays, CT scans, or ultrasounds of the affected area. Treatment options range from over-the-counter NSAIDs for mild to moderate pain to prescription opioids for severe pain.
Example 1: A patient experiences persistent pain in their abdomen three weeks after an appendectomy. The pain is severe and localized to the incision site., Following a knee arthroscopy, a patient reports ongoing pain and stiffness in the joint, limiting their range of motion. This pain has persisted for two months., A patient undergoes a tonsillectomy and experiences significant throat pain for several weeks post-operatively, making it difficult to swallow. This is distinct from any pain at the surgical site itself.
Documentation should clearly link the pain to the specific procedure performed.The onset, duration, character, location, and severity of pain should be detailed.Objective findings from the physical exam, such as tenderness, swelling, or limited range of motion, should be documented. Results of any imaging or diagnostic tests should also be included.If pain is due to a complication of the procedure, this should be explicitly stated.
** It is crucial to differentiate G89.18 (Other acute postprocedural pain) from chronic postprocedural pain (G89.28). Acute pain is generally considered to last for less than 3 months, whereas chronic pain persists beyond this timeframe. It's important to accurately document the duration of the pain to ensure the correct code is applied.This code replaces the ICD-9-CM code 338.18 (Other acute postoperative pain). The terminology shift from "postoperative" to "postprocedural" broadens the scope to include pain following procedures that are not strictly surgical.
- Payment Status: Active
- Specialties:Pain Management, Surgery (relevant to the specific procedure), Anesthesiology.
- Place of Service:Inpatient Hospital, On Campus-Outpatient Hospital, Off Campus-Outpatient Hospital,Office, Home, Skilled Nursing Facility,Ambulatory Surgical Center, Other Place of Service (if applicable).