PART I

TOPICS AND CODES

SCHEME FOR CODING CHRONIC PAIN DIAGNOSES

The digital portion of the codes is explained first, followed by the letters used as suffixes.
The first digit (Axis I), concerned with the regions, has generally not been difficult to complete. If a
patient has pain in more than one region, two codes should be completed for that patient.
The second digit (Axis II) also has generally not been difficult to complete, but the details in this area
are open to debate. For example, migraine has been coded, in accordance with the belief of some
specialists, as a disorder of the central nervous system, but others might think that it should be coded as a
disorder of the vascular system. Again, we should emphasize the practical aspect of the matter: provided
that the code is available and useful to those who accept criteria for migraine in accordance with the
descriptions provided, the theoretical position adopted in regard to the second digit is not necessarily
important.
The third digit (Axis III) deals with the characteristics of the pain episode. It is not controversial, but
some judgment is required in deciding whether a condition is continuous with exacerbations or merely
continuous.
The fourth digit (Axis IV) has to be filled in for each patient according to his or her particular report
as to the severity or chronicity of his or her illness. Accordingly, it is shown as an X throughout the
tabulation of codes in association with descriptions here.
The fifth digit (Axis V) is open to most argument because there is a great uncertainty about many of
the mechanisms involved in the production of pain in different conditions. Again, it should be said that
provided that the coding arrangements give each syndrome a specific and individual number or code, it is
not important whether the ultimate truth of the cause of the syndrome be expressed in that code or not. In
any case, since some syndromes have the same final code for the five digits, it has become necessary to
distinguish them by adding a letter-a, b, c, etc.-in the sixth place. In certain instances the letter a has
been used to indicate acute conditions compared with chronic conditions that share the same five digits.
The leading example of this is acute tension headache. For the most part, however, the letter a in the
sixth place merely indicates the first of several conditions to be described with the same five digits.
The letters S and R are used after the digits for the codes that identify spinal and radicular pain,
respectively. Where both occur in the same location, the letter C, for combined spinal and root pain, is
preferred.
A full list of those codes allocated so far is provided below. Before examining the value of the coding
system, the reader may find it helpful to look at descriptions of conditions with which he or she is familiar
and to consider if the codes do justice, or in his or her view any sort of injustice, to them. After that it may
be worthwhile to compare the codes for the general syndromes with each other, and then compare with
each other those where the same condition affects different parts of the body.
Give priority to the main site of the pain.
Axis I: Regions: Record main site first; record two important regions separately. If there is more than one
site of pain, separate coding will be necessary. More than three major sites can be coded, optionally, as
shown.
Head, face, and mouth
Cervical region
Upper shoulder and upper limbs
Thoracic region 300 Abdominal region
Lower back, lumbar spine, sacrum, and coccyx
Lower limbs
Pelvic region
Anal, perineal, and genital region

000
100
200
400
500
600
700
800

More than three major sites

Axis II: Systems

900

Nervous system (central, peripheral, and

autonomic) and special senses; physical
disturbance or dysfunction
Nervous system (psychological and social)*
Respiratory and cardiovascular systems
20
Musculoskeletal system and connective tissue
Cutaneous and subcutaneous and associated glands
(breast, apocrine, etc.)
Gastrointestinal system
Genito-urinary system
Other organs or viscera (e.g., thyroid, lymphatic,
hemopoietic)
More than one system
Unknown

00

10
30
40
50
60
70
80
90

Note: The system is coded whose abnormal functioning produces the pain, e.g., claudication = vascular.
Similarly, the nervous system is to be coded only when a pathological disturbance in it produces pain.
Thus pain from a pancreatic carcinoma = gastrointestinal; pain from a metastatic deposit affecting bones
= musculoskeletal.
* To be coded for psychiatric illness without any relevant lesion.
Axis III: Temporal Characteristics of Pain: Pattern of Occurrence
Not recorded, not applicable, or not known
Single episode, limited duration (e.g., ruptured
aneurysm, sprained ankle)
Continuous or nearly continuous, nonfluctuating
(e.g., low back pain, some cases)
Continuous or nearly continuous, fluctuating
severity (e.g., ruptured intervertebral disc)
Recurring irregularly (e.g., headache, mixed type)
Recurring regularly (e.g., premenstrual pain)
Paroxysmal (e.g., tic douloureux)
Sustained with superimposed paroxysms
Other combinations
None of the above

0
1
2
3
4
5
6
7
8
9

Axis IV: Patients Statement of Intensity: Time Since Onset of Pain*

Not recorded, not applicable, or not known
Mild -I month or less
.1
Medium
-1 month to 6 months
-more than 6 months
-1 month or less

.2
.3
.4

Severe
-I month to 6 months
-more than 6 months

.5
.6

.0

-1 month or less

.7

-1 month to 6 months
-more than 6 months

.8
.9

* Decide the time at which pain is recognized retrospectively as having started, even though the pain may
occur intermittently. Grade for intensity in relation to the level of current pain problem.
Axis V: Etiology
Genetic or congenital disorders (e.g., congenital dislocation)
.01
Trauma, operation, burns
.01
Infective, parasitic
.02
Inflammatory (no known infective agent), immune reactions
.03
Neoplasm
.04
Toxic, metabolic (e.g., alcoholic neuropathy, anoxia, vascular, nutritional, endocrine), radiation .05
Degenerative, mechanical*
.06
Dysfunctional (including psychophysiological)
.07
Unknown or other
.08
Psychological origin (e.g., conversion hysteria, depressive hallucination).
.09
Note: No physical cause should be held to be present, nor any pathophysiological mechanism
* For example, biliary colic or lumbar puncture headache would be mechanical.
For example, migraine, irritable bowel syndrome, tension headache. Note: Include syndromes where a
pathophysiological alteration is recognized. Emotional causes may or may not be present.
Examples:
Mild postherpetic neuralgia of T5 or T6
6 months duration

303.22e

Severe tension headache

More than 6 months duration

033.97c

Severe primary dysmenorrhea

Duration not recorded

765.07

TOPICS AND CODES

The arrangement of topics and codes follows the plan that was adopted in the first edition. Relatively
generalized syndromes are presented first, followed by regional ones. Appropriate codes are provided.
Because of the substantial changes in the treatment of spinal pain and radicular pain, it has been necessary
to alter some of the numbering of the groups-for example, placing cervical spinal pain, thoracic spinal
pain, and associated radicular syndromes together in Group IX, whereas lesions of the brachial plexus,
which used to occupy Group X, have been placed with pain in the shoulder, arm, and hand as Group XI.
Groups XXVI-XXIX are used for the revised versions of lumbar and sacrococcygeal and diffuse spinal
pain and associated radicular pains. Inevitably some of the numbering within groups has also been
changed, but as far as possible the original numbering has been retained so as to require the minimum of
adaptation from existing data banks based upon the first edition.
Many new codes have been provided, mostly without description, and a number of old codes have
been somewhat revised for greater accuracy and to make each code specific and individual. The following
use of codes is particularly noteworthy.

In the case of spinal and radicular pains, the additional suffixes S and R are used. Where one is used it
indicates that only spinal or only radicular pain is evident. Where both additional suffixes might be used
because both phenomena are present, the letter C (for Combined spinal and root pain) is preferred. Many
spinal codes will be usable with radicular codes. A few spinal codes theoretically should never give rise to
radicular pain, e.g., fracture of a spinous process. A number more rarely give rise to radicular pain but
theoretically could do so, e.g., infection of a vertebral body. In these circumstances the R codes have been
provided for relative completeness but will rarely, if ever, be required.
Note: X = to be completed individually in each case
If there is no code:
(a)
check the introduction to see if the item has been rejected, e.g., atypical facial pain;
(b)
construct your own code or use the miscellaneous category 99X.X8; or
(c)
code as undiagnosed: X9X.X8.
Note that construction of a new code will require a complete challenge because of the existence of many
possible overlapping codes. The editors will be pleased to advise on the possibility of assistance in this
respect.
The first part of the list of topics and codes follows. The second part begins on p. 17 after the discussion
on radiculopathy.