Should I report the ICD-10 code R52 (Pain, unspecified) when the exam is negative and the only reason documented by the ordering physician for the outpatient examination is pain?
No, do not report the pain, unspecified code. As published in Coding Clinic, First Quarter 2006, When the only documentation specified by the physician is pain, assign the appropriate code for pain of the site that is being examined. If there are findings on the x-ray, code the findings. It is appropriate to code what is known at the time of code assignment. When available, coders may use the x-ray results to provide greater specificity. In the outpatient setting, when the physician has interpreted a diagnostic test, the diagnosis may be modified based on physician interpretation. This advice is consistent with that previously published in Coding Clinic, Second Quarter 2002, page 3, and First Quarter 2000, page 4.
Nelly Leon-Chisolm, Director of Coding and Classification at the American Hospital Association (AHA), has confirmed that this guidance holds true for ICD-10 as it did for ICD-9.