HCC 40 – Rheumatoid Arthritis

We’re focusing on Rheumatoid Arthritis.

Rheumatoid Arthritis (RA) is a chronic autoimmune disease that progresses over time. It’s characterized by pain, swelling, and inflammation in the joints and surrounding tissues. It can also affect other organs in the body.

Things to remember when documenting and coding RA:

• Laterality
• Site
• Joint vs. organ
• With Rheumatoid factor (Seropositive) vs. without Rheumatoid factor (Seronegative)

ICD 10 Categories for RA

Rheumatoid Arthritis with Rheumatoid Factor

Rheumatoid Arthritis without Rheumatoid Factor

 Other Rheumatoid Arthritis

**Add fifth character to designate site:

• 0 – unspecified site
• 1 – shoulder
• 2 – elbow
• 3 – wrist
• 4 – hand
• 5 – hip
• 6 – knee
• 7 – ankle and foot
• 9 – multiple sites

Add sixth character to designate laterality:

• 1 – right
• 2 – left
• 9 – unspecified side

Examples:

Patient 1: 89-year-old female referred to Rheumatology for shoulder pain and stiffness. Patient has pain and stiffness in multiple joints and complains of swelling in both wrists and hand. This has been going on for many months.

Patient is diagnosed with seronegative rheumatoid arthritis affecting multiple joints.

The correct code for this scenario is:
M06.09 – Rheumatoid arthritis without rheumatoid factor, multiple sites

Patient 2: 51-year-old female returns to rheumatology clinic for follow up on seropositive RA of right wrist.

The correct code for this scenario is:
M05.731 – Rheumatoid arthritis with rheumatoid factor of right wrist without organ or systems involvement

Notice that in both examples the laterality and site were documented with ease.

For more coding tips, check out the rest of Coding Counts, or if you have any questions, email us directly at [email protected].