When coding for postoperative pain not specified as acute or chronic, how should the encounter be recorded?

In situations where postoperative pain is not explicitly specified as acute or chronic, it is appropriate to code it as acute pain. This approach aligns with the principles of medical coding, which often categorize postoperative pain as acute by default since it typically arises suddenly and is directly associated with recent surgical interventions.

Specifying acute pain aids in tracking treatment and management strategies that are often necessary in the immediate postoperative context. Furthermore, acute pain typically denotes a condition that is temporary and associated with a specific event, such as surgery, which is relevant for accurate medical record-keeping and insurance coding purposes.

Conversely, chronic pain generally refers to ongoing pain that persists for an extended period, often beyond the normal healing time, which may not apply in this scenario. Routine pain and severe pain codes are not standard categories used for this specific situation, making acute pain the most accurate choice.