Guidelines for treating patients with rheumatoid arthritis

Disease-modifying anti-rheumatic drug therapy for rheumatoid arthritis is a HEDIS^®** measure used to determine Medicare star ratings. It assesses RA patients ages18 and older who filled at least one ambulatory DMARD prescription in the measurement year.

Why DMARD therapy?
Aggressive early treatment of RA is essential to helping prevent long-term damage and disability, and several major studies have documented treatment benefits. For instance, DMARD therapy increases quality of life more effectively than other treatment strategies.

According to the American College of Rheumatology, patients with a confirmed RA diagnosis should be treated with a DMARD regardless of the severity or how long they have had RA, unless contraindicated.

Although patients with RA may be stabilized with an anti-inflammatory or steroidal medication, such as prednisone, DMARD therapy is the only treatment that helps prevent further erosion and damage to joints. Anti-inflammatory or steroidal medication doesn’t.

Despite these benefits, managing providers should still see all of 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.

**HEDIS^® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Ensuring accurate diagnosis and coding
Be sure claims submitted are consistent with appropriate diagnosis coding guidelines, below. 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.

Please note these ICD-10 coding guidelines:

• Don’t code diagnoses using such terms 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.

Clinical criteria for RA
Joint pain or arthritis isn’t always RA. 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
• Presence of swelling in joints, especially multiple joints
• Erosion showing on X-ray of joints
• Metacarpophalangeal and proximal interphalangeal joint involvement
• Morning stiffness lasting more than 45 minutes
• Positive test results for cyclic citrullinated peptide or rheumatology factor
• Rheumatoid nodules
• Symmetrical joint pain
• Elevated erythrocyte sedimentation rate, or ESR, with joint pain, swelling, fevers, rash or weakness
• Weakness, such as a new onset in difficulty rising from a chair, along with an elevated ESR and creatinine kinase
• New blue or white color changes in the fingers and toes, particularly with ulcers

DMARD formulary enhancements
Remember — we’ve also enhanced the formulary for DMARD therapy, including removing prior authorization requirements for Humira^® and Enbrel^®, and lowering member cost share for three other DMARD drugs. Refer to this previous Record article for more information.

^Available to Medicare Plus Blue^SM members for the plan’s lowest copays.

None of the information included herein is intended to be legal advice and as such it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with all applicable state and federal laws and regulations.