Are you getting paid for following best practice guidelines for rheumatoid arthritis?

Disease-modifying anti-rheumatic drug therapy, or DMARD, for rheumatoid arthritis is one of the HEDIS^® measures used to determine Medicare star ratings. It assesses RA patients ages 18 and older who were diagnosed with RA at two separate visits and who filled at least one ambulatory prescription for DMARD in the measurement year.

Why DMARD therapy?
Several major studies have documented the benefits of aggressive early treatment, which is essential in helping prevent long-term damage and disability from RA. DMARD therapy increases the quality of life more effectively than other treatment strategies. According to the American College of Rheumatology, patients with a confirmed diagnosis should be treated with DMARD therapy regardless of severity or how long they’ve had RA unless contraindicated.

DMARD therapy is the only treatment that helps prevent further erosion and damage to joints. Managing providers should see their patients undergoing DMARD therapy treatment in follow-up visits at least four times a year to monitor the disease therapy effectiveness and any adverse events with the treatment.

Provider incentive for DMARD therapy
Blue Cross Blue Shield of Michigan provides $100 to participating primary care physicians for each Medicare Advantage member with RA who fills at least one prescription for DMARD therapy each calendar year. Blue Cross offers this incentive for DMARD treatment because it follows RA national guidelines.

Referring patients to a rheumatologist
Referral of patients to a rheumatologist is highly recommended to confirm and treat the disease because:

• Suspected and early onset of RA may resemble other forms of inflammatory arthritis.
• Patients with RA, when appropriately treated, can experience a reduction of disease progression, joint damage, long-term disability, elimination of surgery, lower disease activity and improved chances of disease remission.

Ensuring accurate diagnosis and coding
Be sure claims submitted are consistent with appropriate diagnosis coding guidelines. Confirm a diagnosis of RA, versus osteoarthritis or joint pain, before entering it on claims. Members’ RA claims are sometimes coded inaccurately when they also have joint pain or other signs and symptoms that must be addressed. RA claims shouldn’t be submitted unless the diagnosis has been confirmed.

Note these ICD-10 coding guidelines:

• Don’t code diagnoses using terms such as “probable, suspected, questionable, rule out, working diagnosis” or similar terms indicating uncertainty. Code conditions to the highest degree of specificity, including symptoms, signs, abnormal test results or other reasons for the visit.
• Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis hasn’t been confirmed by the provider.

DMARD medications
Excellent treatment responses can be achieved with a wide variety of nonbiologic and biologic DMARD therapies. Below are some examples:

**Tier 1 preferred generic drug that offers the lowest member cost sharing

Exclusions
Patients are excluded from the rheumatoid arthritis measure when claims in the measurement year support one of the following:

• Patient is in hospice.
• Patient is 66 or older and enrolled in an institutional Special Needs Plan, or I-SNP, or living long-term in an institutional setting.
• Patient is age 81 or older with frailty.
• Patient is pregnant.
• Patient was dispensed a dementia medication.
• Diagnosis of HIV any time in the patient’s history.

Also excluded are patients ages 66 through 80 with two advanced illness claims in the measurement year or the year prior to the measurement year and one frailty claim.

Note: If your patient can’t tolerate DMARD therapy, it’s important to include advanced illness and frailty diagnosis codes on your office visit claims when appropriate.

Following is a sample list of frailty ICD-10 codes recognized by HEDIS:

• R26.2 — Difficulty in walking, not otherwise classified
• R26.89 — Other abnormalities of gait and mobility
• R26.9 — Unspecified abnormalities of gait and mobility
• R41.81 — Age-related cognitive decline
• R53.1 — Weakness
• R53.81 — Other malaise
• R53.83 — Other fatigue
• R54 — Age-related physical debility
• Z73.6 — Limitation of activities due to disability
• Z74.09 — Other reduced mobility
• Z91.81 — History of falling
• Z99.81 — Dependence on wheelchair

HEDIS^®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance.