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Pain assessment not documented as being performed, documentation the patient is not eligible for a pain assessment using a standardized tool at the time of the encounter

HCPCS code

Similar Codes


ICD10CM codes

G89 - Pain, not elsewhere classified
G89.2 - Chronic pain, not elsewhere classified
G89.1 - Acute pain, not elsewhere classified
Y65.52 - Performance of procedure (operation) on patient not scheduled for surgery
Z41.9 - Encounter for procedure for purposes other than remedying health state, unspecified
Z53.20 - Procedure and treatment not carried out because of patient's decision for unspecified reasons
G89.28 - Other chronic postprocedural pain
G89.18 - Other acute postprocedural pain
Z53.21 - Procedure and treatment not carried out due to patient leaving prior to being seen by health care pr
Z53.2 - Procedure and treatment not carried out because of patient's decision for other and unspecified reas

HCPCS codes

G8442 - Pain assessment not documented as being performed, documentation the patient is not eligible for a p
G8939 - Pain assessment documented as positive, follow-up plan not documented, documentation the patient is
G8540 - Functional outcome assessment not documented as being performed, documentation the patient is not el
G8509 - Pain assessment documented as positive using a standardized tool, follow-up plan not documented, rea
G8732 - No documentation of pain assessment, reason not given
G8731 - Pain assessment using a standardized tool is documented as negative, no follow-up plan required
G9251 - Documentation of patient with pain not brought to a comfortable level within 48 hours from initial a
G9227 - Functional outcome assessment documented, care plan not documented, documentation the patient is not
G8541 - Functional outcome assessment using a standardized tool not documented, reason not given
G8535 - Elder maltreatment screen not documented; documentation that patient is not eligible for the elder m

CPT4 codes

1126F - Pain severity quantified; no pain present (COA) (ONC)
96160 - Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) wi
1125F - Pain severity quantified; pain present (COA) (ONC)
1124F - Advance Care Planning discussed and documented in the medical record, patient did not wish or was no
96161 - Administration of caregiver-focused health risk assessment instrument (eg, depression inventory) for
0521F - Plan of care to address pain documented (COA) (ONC)
3341F - Mammogram assessment category of negative, documented (RAD)
4555F - Patient did not receive inhalational anesthetic agent (Peri2)
99499 - Unlisted evaluation and management service
99600 - Unlisted home visit service or procedure