When assessing for osteoarthritis and rheumatoid arthritis (RA), do not use a “rule-out diagnosis code” until the diagnosis is confirmed. Code the patient’s symptoms (for example, pain in joints M25.50) until the diagnosis is confirmed.
Never code “suspected” conditions in the outpatient setting. Instead, base coding on the documented signs and symptoms or the current condition. Rheumatoid arthritis generally is confirmed by an x-ray of the affected joint and lab work to determine the presence of RA factor.
Use these diagnosis codes for confirmed rheumatoid arthritis:
Proper ICD-10-CM code assignment for rheumatoid arthritis depends on the location and laterality of affected joint. Please refer to the ICD-10-CM Official Codebook for a complete list and remember to code to the highest level of specificity.
Examples of correct coding:
|PCP exam to rule out rheumatoid arthritis
in the right hand
|When the x-ray is negative and the lab work does not indicate the presence of RA factor, the services rendered should be coded with only the symptom documented (for example, M25.541 pain in joints of right hand.)|
|PCP follow-up visit after radiological exam||If exam showed progressing damage to right metacarpophalangeal joint and abnormal lab results, the PCP can code a confirmed diagnosis (for example, M06.841 other unspecified rheumatoid arthritis, right hand) and discuss ongoing treatment options.|
NCQA requirements for treating RA
The NCQA HEDIS measure evaluates the percentage of members who were diagnosed with RA and who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD).
We contact treating providers when a claim is submitted with a diagnosis of RA and a corresponding prescription for a DMARD has not been filled. To avoid submitting claims with a rule-out diagnosis, be sure to code only confirmed diagnoses of RA and monitor patients’ DMARD prescriptions, such as Methotrexate or Rituximab.
Until a diagnosis is confirmed, code the symptom and avoid the use of a rule-out diagnosis code to prevent your patient being included in the measure incorrectly.