By far one of the most frequently abused impairments by disability insurers is “chronic pain.” Classified as self-reported and “subjective”, insurers tend to reject claims with a primary diagnosis of “chronic pain”, ICD-10 code G89.4. “Chronic Pain Syndrome” is immediately identified as “subjective” when the word “Syndrome” is included in the primary diagnosis.
Supporting a disability claim with an impairment identified as “chronic pain syndrome” can be difficult particularly when the deck is stacked with predetermined insurer strategies to not pay claims. And, the reality of the impairment is that chronic pain IS subjective and there are no tests that diagnose its existence or severity.
Chronic pain is the body’s response, or warning bell, that all is not well. In addition, pain as such, is “relative” meaning that one person’s level of pain described as severe can also be described by another person as mild, or just a nuisance. Insurers tend to wonder if a patient’s description of severe migraine pain isn’t really just a headache described by someone who is less tolerant of pain.
Even if this were true, does it then follow that persons less tolerant of pain aren’t experiencing some sort of trauma that prevents them from working? The problem, of course, is trying to define “an exact” from a phenomena that is “unmeasurable and intangible”.
Treating physicians themselves misunderstand insurer motivations and continue to document primary diagnoses as “chronic pain.” The insurance “new normal” will reject that primary diagnosis as subjective, and they are not entirely wrong.
Insureds and their physicians SHOULD NOT document Chronic Pain G89.4 as a primary diagnosis, but rather focus more on the causes of the pain that that are usually derived from accident or injury, failed back/neck surgeries, shoulder/knee injuries or surgery, strain/sprains etc.
For example, an insured suffering from chronic pain resulting from a T12 spine herniation should list the ICD-10 code for spine herniation, status post surgery with chronic pain as a secondary due to physical diagnosis. When insureds and their physicians point to chronic pain as primary, claim results are very disappointing.
Depending on the circumstances of each case, migraine headache could similarly be positioned as secondary, for example, as the result of a cervical injury/surgical procedure. My point is that when chronic pain is documented as a primary diagnosis, documentation in support of a disability claim will be lacking and the real cause of the pain is omitted from the record.
Chronic pain is best positioned for a disability claim when it is documented as secondary to its cause rather than a physical manifestation on its own.
Again, treating physicians may also not be describing chronic pain very well, adding to the subjectivity classification of pain. And clearly in today’s new normal of claims investigation, it is not enough to diagnose patients with Chronic Pain, ignoring the etiology or causation of the physical symptoms causing pain. Pain just does not happen without a reason, particularly pain severe enough to keep someone from working.
For example, when physicians document Fibromyalgia and Chronic Pain Syndrome as separate diagnoses, do they mean chronic pain as a symptom of FMS, or chronic pain as a separate diagnosis? Chronic pain from what? Fibromyalgia? Then, the diagnosis should be, “Fibromyalgia with moderate to severe chronic pain in 11 of 18 tender points tested.”
Insurers are indeed holding medical documentation to support disability claims to a higher standard of reporting. Of course they are, since it is to their advantage to do so. At best, claims listing chronic pain as a primary diagnosis are limited to 24 months under Mental and Nervous provisions, and at worst are denied outright for lack of evidence.
To make matters worse, new definitions in the ICD-10 Diagnostic Manual of Psychological Disorders (DSM) gives insurers more legitimacy is alleging chronic pain is somaticized, exaggerated or imagined. This is now true of all diagnoses listed as “Syndromes”.
This and other articles I’ve written lately attempt to educate insureds to the new reality of disability claims management, but unfortunately I suspect insureds are reluctant to discuss documentation with their physicians, possibly to their own claim demise.
Please note that although I don’t usually write my articles to sell my business, I am here to help insureds who may “not get” the new normal investigation of claims and how they can improve reporting. Investigation processes are not the same now as they used to be, and with the hungry vultures out there for 4th quarter profitability, I thought I would offer my services to those who may need assistance.
If you would like more information on how to become a client, please feel free to contact me. If not, and you’ve decided to continue managing on your own, you will need to be more aware of the “new documentation requirements” needed to meet “the new normal” standards of proof of claim.
