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v1.0.0
ICD-10 Guide
DiagnosesPost Op Pain

Post Op Pain

ICD-10 Coding for Post-Operative Pain(G89.12, G89.18, G89.22, G89.28)

PRIMARY SPECIALTYOrthopedics
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Post Op Pain?
Essential facts and insights about Post-Operative Pain

Key Clinical Considerations:

  • Pain at the surgical site post-operatively
  • Increased pain with movement or palpation
  • Swelling or tenderness around the surgical area

Clinical Information

Clinical Criteria & Documentation Requirements

  • Date and type of surgery performed
  • Pain assessment scale used
  • Post-operative care instructions and follow-up plans

Coding Guidelines

Usage Guidelines & Examples

  • Use G89.11 for specific post-operative pain; G89.18 for other acute pain.
  • Common errors include using incorrect codes for chronic pain or failing to document pain severity.

Code Exclusions

Important Exclusions

  • Chronic pain conditions unrelated to surgery
  • Codes for pain management unrelated to post-operative care

Related ICD-10 Codes

Primary Codes
G89.11
Postoperative pain, not elsewhere classified
G89.18
Other acute postprocedural pain
Ancillary Codes
T81.4XXA
Differential Codes
G89.22
G89.28
G89.12
G89.18

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Orthopedics

Specialty Applications

  • Post-operative orthopedic patients
  • Outpatient and inpatient surgical settings

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

What are the documentation requirements?

Document the type of surgery, pain level, and any interventions.

What are the billing considerations?

Ensure accurate coding to reflect the complexity and duration of post-operative pain.