Coding Tip: Rheumatoid Arthritis

OHN provides the knowledge, resources, processes, and technology you need for success in value-based care so you can do more of what you love –taking care of patients. Each month, we share one coding tip and highlight one best practice advisory (BPA) to help to support your clinical documentation efforts.

Additionally, the clinical documentation excellence (CDE) team is here to support you – email riskadjustment@ochsner.org with any questions.

Capturing and Coding Rheumatoid Arthritis

Rationale

-- Rheumatoid arthritis is a chronic, systemic inflammatory disorder that primarily affects the joints, causing pain, swelling and stiffness.

-- It is an autoimmune disease in which the body’s immune system attacks the body’s own tissues.

-- While the inflammatory response of rheumatoid arthritis primarily affects joints, it is a systemic inflammatory disorder that can also impact organs, such as the skin, eyes, heart, lungs and blood vessels.

-- Rheumatoid arthritis usually begins after age 40, but it can occur at any age.

-- The exact cause of rheumatoid arthritis is not known. Some of the possible causes include:

• Genetic factors (inherited from parent to child)
• Environmental triggers
• Hormones (rheumatoid arthritis is more common in women)

-- Some people with this disease experience periods in which symptoms get worse (flares) or better (remissions).

-- Others have a severe form of the disease that is active most of the time, lasts for many years or a lifetime, and leads to serious joint damage and disability.

-- Symptoms can include:

• Joint pain, warmth, redness and swelling
• Joint stiffness, in the morning or after inactivity, that can last for hours
• Fatigue
• Occasional fever
• Firm lumps (called rheumatoid nodules) that grow under the skin close to affected joints
• Loss of appetite and weight loss

How to Code & Document

Subjective

• In the subjective section of the office note, document any current symptoms of rheumatoid arthritis reported by the patient (joint pain, swelling or stiffness, fatigue, episodes of fever, etc.)

Objective

• Include any current associated physical exam findings, such as joint deformity, and related laboratory or diagnostic imaging test results.

Assessment

-- Specificity: Describe the final rheumatoid arthritis diagnosis to the highest level of specificity, including whether the patient is seropositive or seronegative, which joints are affected, whether there is a lateral presentation, and the patient’s current status – active versus in remission.

• Clearly link associated conditions or manifestations of rheumatoid arthritis by using linking terms such as “due to,” “secondary to” or “associated with.”
• Include the patient’s current status, such as stable or improved.
• Document details of any organ involvement.

-- Abbreviations

• Limit – or avoid altogether – the use of acronyms and abbreviations.
• While “RA” is a commonly accepted medical abbreviation for rheumatoid arthritis, this abbreviation can have other meanings (for example, reactive arthritis).
• The meaning of an abbreviation can sometimes be determined based on context, but this is not always true.
• Spell out the condition’s name in full when first mentioning it in the office note, with the abbreviation in parentheses, i.e., “rheumatoid arthritis (RA).”
• You can use the abbreviation “RA” in subsequent mentions, except in the final assessment, where the diagnosis should again be documented in full.

Suspected vs. Confirmed

• Do not document rheumatoid arthritis as a confirmed condition if it is only suspected and not truly confirmed.
• Document signs and symptoms in the absence of a confirmed diagnosis.
• If rheumatoid arthritis is a confirmed diagnosis, avoid describing it with terms that imply uncertainty, such as “apparently,” “likely,” “consistent with,” “probable,” etc.

Treatment Plan

-- Document a specific and concise treatment plan, which includes elements like:

• Referral to rheumatologist
• Laboratory tests and diagnostic imaging
• Patient education, including self-management
• A date or time frame for the patient’s next appointment

Treatment With Disease-Modifying Anti-Rheumatic Drugs (DMARDs):

-- The American College of Rheumatology advises that patients with an established diagnosis of rheumatoid arthritis should be treated with a DMARD, even in the first six months after the diagnosis, unless a contraindication, inactive disease or patient refusal is documented.

-- For your patients with rheumatoid arthritis, document:

• Specific details of current DMARD therapy in the treatment plan section of the record – not simply in the medication list – with clear linkage of the medication to rheumatoid arthritis OR
• Specific information describing any contraindication to DMARD therapy
• A notation that the patient’s rheumatoid arthritis is inactive
• A statement of patient refusal of DMARD therapy and the reason for refusal

Coding Major Depression

Rheumatoid arthritis and its associated disorders classify to the following categories:

-- MØ5 Rheumatoid arthritis with rheumatoid factor, excludes rheumatic fever (IØØ)

• Juvenile rheumatoid arthritis (MØ8.)
• Rheumatoid arthritis of spine (M45.-)

-- MØ6 Other rheumatoid arthritis

-- Fourth, fifth and sixth characters are used with categories MØ5 and MØ6 to further specify the type of rheumatoid arthritis, as well as the particular joint affected with laterality (left, right or unspecified).  

Severe joint pain is a characteristic of rheumatoid arthritis and should not be coded separately from an already confirmed rheumatoid arthritis diagnosis.

Avoid coding rheumatoid arthritis as a confirmed condition if it is documented as suspected and not truly confirmed. Rather, code the signs and symptoms in the absence of a confirmed diagnosis.

Seropositive vs. Seronegative Rheumatoid Arthritis

-- Seropositive– category MØ5

• In most cases of rheumatoid arthritis, the patient’s blood tests positive for rheumatoid factor and/or certain other antibodies (anti-CCP antibodies).
• Positive blood tests indicate the patient has seropositive rheumatoid arthritis, meaning the patient possesses the antibodies that cause an attack on joints and lead to inflammation.

-- Seronegative– category MØ6

• Patients can develop rheumatoid arthritis without the presence of these antibodies. This is referred to as seronegative rheumatoid arthritis.
• Seronegative patients are those who do not test positive for rheumatoid factor or anti-CCPs.

Rheumatoid Arthritis in Remission

• Rheumatoid arthritis is a chronic and incurable systemic condition that affects the patient for the rest of their life.
• With early and aggressive treatment, many patients can achieve long periods of remission in which inflammation is greatly reduced or absent with no active signs of disease.
• Thus, rheumatoid arthritis described as “in remission” should be coded when it requires or affects patient care, treatment or management – as long as there are no contradictions or conflicts elsewhere in the record that suggest rheumatoid arthritis is not a true or confirmed diagnosis.

Long-Term (Current) Use of Immunosuppressant Drugs

-- Immunosuppressant drugs are commonly used in the treatment of autoimmune diseases such as rheumatoid arthritis.

-- A code for adverse effect code is not assigned when the medication has achieved its intended result in lowering the patient’s immune response to rheumatoid arthritis.

• Rather, assign code D84.821 Immunodeficiency due to drugs.

-- ICD-10-CMdoes not provide a specific code to identify long-term use of immunosuppressant drugs.

• Assign code Z79.899, Other long-term (current)drug therapy, to report long-term use of immunosuppressant drugs.

Rheumatoid Arthritis With or Without Organ Involvement

• When a medical record documents a current diagnosis of seropositive rheumatoid arthritis of a specific joint(s) and there is no mention of any type of organ involvement, the default is “without organ involvement.”
• Assign a code for “with organ involvement” only when the record documents organ involvement.