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Pain Assessment

Clinical Basis

Pain should be considered the fifth vital sign and assessed with each visit. Pain management in this population is important because it allows for effective mobilization and functional independence. It also may result in decreased morbidity and healthcare expenditures.

Pain assessment can be particularly difficult in elderly patients for the following reasons:

  • Underreporting of discomfort because patients do not want to complain
  • Use of pain to mask other newly developing physical or cognitive disabilities
  • Decreases in hearing and visual acquity

Clinical Guidelines

Use both single-dimensional and multi-dimensional scales in the assessment of pain:

  • Single-dimensional scales assess a single dimension of pain and, through patient self-reporting, measure only pain intensity; these scales are useful in acute pain when the etiology is clear. For example:

  • An alternative to a visual scale is to use a verbal descriptor scale. For example, the Melzack and Torgeson scale uses five descriptors: mild, discomforting, distressing, horrible and excruciating. This may be the easiest tool for the elderly to use because it allows patients to use common words to describe what they are feeling.
  • Multi-dimensional scales are useful in complex or persistent acute or chronic pain. These scales measure the intensity, nature and location of pain, as well as, in some cases, the impact that pain is having on patients’ activities or moods.
  • The WILDA approach offers a concise template for assessment of patients with acute and chronic pain, focusing on:

Words to describe pain




Aggravating or alleviating factors

Coding and Documentation Guidance

Documentation should indicate the pain severity quantified (CPT II 1125F) or that pain is absent (CPTII 1126F).


CPT II Codes

1125F - Pain severity quantified; pain present

1126F - Pain severity quantified; no pain present


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