Reporting A Diagnosis Code

WSI requires a provider to report the most specific diagnosis code reflective of the injury treated instead of using the standalone diagnosis code of “pain”. The following are important points regarding the use of “pain” as the standalone diagnosis code:

• May cause prolonged claim and bill adjudication.
• May complicate the decision for acceptance of a claim.
• May result in WSI needing to contact the provider for additional information to clarify the diagnosis.
• Does not align with the General Coding Guidelines, published in the ICD-10-CM Official Guidelines for Coding and Reporting. The Guidelines state, "Specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient’s health condition [….] Diagnosis codes describing symptoms and signs are acceptable for reporting only when the provider has not established a related, definitive (confirmed) diagnosis.”

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