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June 2016

Here are guidelines for treating patients with rheumatoid arthritis

It’s important for providers to follow national guidelines when treating patients diagnosed with rheumatoid arthritis, or RA, to prevent long-term damage and disability. Review of clinical quality data from Blue Cross Blue Shield of Michigan revealed that 20 percent of Blue Cross Medicare Advantage PPO members with RA aren’t being treated properly with Disease Modifying Antirheumatic Drug, or DMARD, therapy.

Why DMARD therapy?
Several major studies documented the benefits of early aggressive treatment for RA. DMARD therapy increases the quality of life more effectively than other treatment strategies.

The American College of Rheumatology recommends that all RA patients be prescribed a DMARD regardless of how active or severe their RA is. Appropriate DMARD treatment can reduce a patient’s disability potential by more than 60 percent.

According to the American College of Rheumatology, correctly diagnosed RA patients should be treated with a DMARD unless indicated otherwise. Once an RA diagnosis has been made, ensure all RA patients are treated according to accepted clinical practice guidelines.

They must receive at least one DMARD prescription each year and be referred to a rheumatologist. Keep in mind that patients receiving a DMARD should be regularly monitored for early detection and management of adverse events that are associated with a specific drug or biologic agent.

Please remember formulary enhancements have been made for DMARD therapy. These include the removal of prior authorization requirements for Humira® and Enbrel®, and that there is a lower member cost share for three other DMARD drugs. Refer to the article “Anti-rheumatic drug benefit changes for Medicare Plus BlueSM and Prescription BlueSM PDP members” in the October 2015 issue of The Record for more information.

Ensuring accurate diagnosis and coding
Members’ claims for RA are sometimes coded inaccurately when they have joint pain or other signs and symptoms that require workup. A claim for RA shouldn’t be submitted unless it’s a confirmed diagnosis. Note that ICD-10 coding guidelines state:

  • Don’t code diagnoses that are probable, suspected, questionable, rule-out, working diagnosis or similar terms indicating uncertainty. Code conditions to the highest degree of certainty for the encounter such as symptoms, signs, abnormal test results or other reason 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 established (confirmed) by the provider.

Joint pain or arthritis isn’t always considered rheumatoid arthritis. The clinical criteria for RA are chronic inflammatory disorder for more than six weeks with four of the following symptoms:

  • Affecting three or more joints
  • Erosion showing on X-ray of joints
  • Metacarpophalangeal, or MCP, and proximal interphalangeal, or PIP, joint involvement
  • Morning stiffness
  • Positive test results for cyclic citrullinated peptide, or CCP, or rheumatology factor, or RF
  • Rheumatoid nodules
  • Symmetrical joint pain
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*CPT codes, descriptions and two-digit numeric modifiers only are copyright 2015 American Medical Association. All rights reserved.
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