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October 2019
Coding corner: Documentation and coding for rheumatoid arthritis
Nearly 1.5 million people in the United States – 70% of whom are women – have rheumatoid arthritis, or RA. Symptoms usually begin between the ages of 30 and 60, but may occur later in life for men. A family history increases the odds of having RA; however, most people with RA have no family history. Although the exact cause of RA is unknown, scientific evidence shows that genes, hormones and environmental factors play a role in the abnormal response of the immune system.
Documentation and coding tips
- Information about coding for RA can be found in Chapter 13 (“Diseases of the Musculoskeletal System and Connective Tissue”) of the ICD-10-CM coding book. Look under “Inflammatory polyarthropathies (M05-M14).”
- Involvement of any joints, body systems and organs should be specified in order to code RA to the highest specificity.
- Most codes have site and laterality designations. Site represents the joint or organ involved.
- For categories where no “multiple site” codes are provided, and more than one joint or organ is involved, multiple codes should be used to represent the different sites involved.
- Rheumatoid factor test results and interpretation should be documented to code to the highest specificity.
The chart below gives some examples of rheumatoid arthritis with or without rheumatoid factor, and with or without organ and systems involvement:
| Condition |
ICD-10 code |
| Rheumatoid lung disease with rheumatoid arthritis of right shoulder |
M05.111 |
| Rheumatoid vasculitis with rheumatoid arthritis of left hip |
M05.252 |
| Rheumatoid arthritis of right ankle and foot with involvement of other organ and systems |
M05.671 |
| Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement |
M05.762 |
| Rheumatoid polyneuropathy with rheumatoid arthritis of right hip |
M05.551 |
| Rheumatoid heart disease with rheumatoid arthritis of right elbow |
M05.321 |
| Rheumatoid arthritis with rheumatoid factor of left shoulder without organ or systems involvement |
M05.712 |
Sources:
**Blue Cross Blue Shield of Michigan doesn’t own or control this website.
None of the information included in this article 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.
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