Throughout the history of international diagnostic coding systems, including the International Classification of Diseases (ICD), pain diagnoses have never been represented systematically. The lack of a coding structure for chronic pain conditions has made it difficult for providers to bill for services and nearly impossible for insurers and other policymakers to truly understand the human and financial impact of chronic pain. This is all set to change.
The New Codes
Approved by the World Health Assembly in May 2019, the revised 11th edition of the ICD (ICD-11) contains, for the first time in history, a coding and classification system for chronic pain. By placing ICD-11’s new coding system into the hands of primary care providers (PCPs), who are becoming more and more responsible for treating the vast majority of patients living with chronic pain, the healthcare system has an exciting new opportunity to consistently and easily measure the incidence, prevalence, and impact of chronic pain, both alone and alongside comorbidities. As IASP Task Force for the Classification of Pain member Blair H. Smith, MD, told PPM, the development of the new code for chronic primary pain is particularly innovative, as it enables “practitioners to recognize chronic pain as a distinct clinical entity, even when an underlying pathology is not apparent. This confers validity on a condition which previously risked going unrecognized, and therefore incompletely assessed and treated.”
Chronic pain, as defined in ICD-11, is pain that recurs or persists longer than three months.1 Under the new classification, this type of pain will be coded using seven main codes, including the new code for “chronic primary pain,” where the chronic pain itself is the disease. The other six main codes are for chronic secondary pain syndromes where the chronic pain was developed in the context of another disease, including cancer-related pain, post-surgical/post-traumatic pain, neuropathic pain, secondary headache or orofacial pain, secondary visceral pain, and secondary musculoskeletal pain.2 Finally, the World Health Organization included two additional codes to cover any pain conditions that do not fit within the seven primary codes, including one for “other specified chronic pain” (to be used only when a new set of diseases is recognized to cause chronic pain) and another for “chronic pain, unspecified” (when it is unclear whether the chronic pain is primary or secondary).3 (Editor’s Note: The ICD-11’s impact on assessing neuropathic pain, was addressed by Scholz in a previous PPM issue.4)
ICD-11 Will Change Daily Primary Practice
The straightforward way that chronic pain will be coded under the new ICD-11, set to take effect in January 2022, will ensure that it is simple and time-efficient for providers to apply the codes in the primary care setting, where consultations with patients are numerous and often all too brief. Under older coding systems, providers had to code creatively as they attempted to fit pain conditions within existing symptom-based codes, diagnostic labels, or treatment-based codes. The new system will allow a patient’s condition to be coded according to what the condition is (chronic postsurgical pain, for example) rather than how the condition is being treated (such as using the “opioids and related analgesics” code found in the ICD-10).
In addition to simplifying the application of ICD-11 at the primary care level, the establishment of a unified classificatory language related to chronic pain conditions has the potential to greatly improve the care of people living with chronic pain.5 First and foremost, the addition of these new codes makes it clear that chronic pain is a centrally important condition in primary care, which should help to reduce the stigma associated with pain conditions. Use of the “chronic primary pain” code may minimize unnecessary procedures and diagnostic exams by shifting the focus from finding a cause for the pain to managing the pain earlier in the patient’s journey. On the other hand, use of the six secondary pain syndrome codes may help to identify patients at high risk for developing complex chronic pain and aid in matching specific patients to appropriate specialists and/or evidence-based treatment pathways sooner rather than later.
Data to be Bolstered by ICD-11 Integration
Beyond improving the treatment of today’s patient, use of the new codes will improve the healthcare system’s ability to measure the incidence, prevalence, and impact of chronic pain. This, in turn, will help to identify the human, financial, and educational needs required to address chronic pain and improve efficient service delivery.6 Clinicians often have limited training in pain management,7,8 which can result in subpar outcomes for patients living with chronic pain; increased documentation of chronic pain as a pervasive problem may lead to improved undergraduate, graduate, and professional education. Insurers will appreciate a coding system that provides them with data that can help guide treatment provision and reimbursement, improve service delivery and timing, and enable them to compare changes across time and regions.
So, with all of these exciting new possibilities, how much time will it take to see practical changes resulting from the new data the codes provide? According to Dr. Smith, “the answer to ‘how much time’ is the same as the answer to ‘how long is a piece of string’. I think, though, we can say that the benefits […] will begin to be seen almost immediately and grow more and more with the passage of time. Chronic pain is so common in primary care that the lag time between the code being introduced into routine care and being able to interrogate datasets will be a matter of weeks.”
However, Dr. Smith’s co-authors, Dr. Antonia Barke and Beatrice Korwisi, are quick to point out that before the new pain codes can be introduced into routine care, each country must first adopt, and then implement, the new coding system. That caveat in mind, “The implementation and use of ICD-11 classification in primary care could, in theory, be very soon,” said Dr. Egil A. Fors, another of Smith’s co-authors, as “…some centers in Norway, Thailand, and Japan have already started to classify chronic pain according to ICD-11 in specialist care.”
The novel coding system for chronic pain found in the revised ICD-11 is simple yet comprehensive and was specifically designed to be easily applied at the primary care level. Use of the system should quickly improve the treatment of individuals living with pain, but its true impact will be felt over time as chronic pain conditions — and their human and financial impacts — are finally measured in such a way that targeted improvements to service delivery and payment structures can be made throughout the healthcare system.
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Photo courtesy of: Practical Pain Management
Originally Published On: Practical Pain Management
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