Pain disorder with related psychological factors

This code signifies a chronic pain condition where psychological factors are judged to play a significant role in the onset, severity, exacerbation, or maintenance of the pain. The pain is real and not feigned, but emotional distress, behavioral patterns, or cognitive processes contribute to the patient's experience of pain and functional impairment.

Apply this code when documentation clearly indicates a primary diagnosis of pain, and a mental health professional or physician has identified a strong psychological component influencing the pain experience. This is often seen in patients with chronic back pain, fibromyalgia, or headache disorders where anxiety, depression, or stress are noted as contributing factors.

• Requires documentation of both pain and the psychological factors influencing it; a simple note of "pain" is insufficient.
• Always sequence the specific pain code (e.g., M54.5 for low back pain) as the primary diagnosis, with this code as a secondary diagnosis.
• Do not use for malingering or factitious disorder; the pain experience is genuine.