Disclaimer
The information provided is intended to assist with support for the documentation accuracy of the diagnoses codes reported to Highmark and not intended to influence clinical or coding judgement. Information regarding any law or regulation does not constitute legal or tax advice and is subject to change based upon the issuance of new guidance and/or change in laws or regulations. Providers should still reference official ICD-10-CM coding guidelines and coding manuals or electronic coding software for accurate reporting of compliant diagnosis codes.
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Agenda
1. Identify types of arthritis
2. Discuss documentation requirements
3. Review related treatments
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Types of Arthritis Types of Arthritis
• Non-Inflammatory • Osteoarthritis
• Inflammatory • Ankylosing Spondylitis • Gout • Juvenile Idiopathic Arthritis • Psoriatic Arthritis • Rheumatoid arthritis
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Differences
Rheumatoid arthritis Osteoarthritis Age of onset May begin at any time in life Usually begins later in life Relatively rapid, over weeks to Speed of onset months Slow, over years
Joint symptoms Pain, swelling, stiffness Achiness and tenderness, but little or no swelling
Often affects small and large joints Often begins on one side of the body and may spread on both sides of the body to the other side. Symptoms begin gradually and are Pattern of joints (symmetrical), such as both hands, often limited to one set of joints, usually the finger affected both wrists or elbows, or balls of joints closest to the fingernails or thumbs, large both feet weight-bearing joints (hips, knees) or the spine.
Duration of morning Less than one hour – returns at the end of the day stiffness Longer than one hour or after periods of activity Presence of symptoms affecting Frequent fatigue and a general feeling the whole body of being ill Whole body symptoms are not present (systemic)
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Coding Rheumatoid Arthritis
Rheumatoid Arthritis with Rheumatoid Factor Rheumatoid Arthritis without Rheumatoid Factor M05.0xx Felty’s Syndrome M06.0xx Rheumatoid arthritis without rheumatoid M05.1xx Rheumatoid lung disease with rheumatoid factor arthritis Other Rheumatoid Arthritis M05.2xx Rheumatoid vasculitis with rheumatoid arthritis M06.1 Adult –onset Still’s disease M06.2xx Rheumatd bursitis M05.3xx Rheumatoid heart disease with rheumatoid M06.3xx Rheumatoid nodule arthritis M06.4 Inflammatory polyarthropathy M05.4xx Rheumatoid myopathy with rheumatoid arthritis M06.8xx Other specified rheumatoid arthritis M05.5xx Rheumatoid polyneuropathy with rheumatoid M06.9 Rheumatoid arthritis, unspecified arthritis M08.00 Unspecified juvenile rheumatoid arthritis of M05.6xx Rheumatoid arthritis with involvement of other unspecified site organs and systems L40.50 Arthropathic psoriasis, unspecified M05.7xx Rheumatoid arthritis with rheumatoid factor L40.51 Distal interphalangeal psoriatic arthropathy without organ or systems involvement L40.52 Psoriatic arthritis mutilans M05.8xx Other rheumatoid arthritis with rheumatoid factor M05.9xx Rheumatoid arthritis w/rheumatoid factor, unspecified
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Rheumatoid Arthritis vs Fibromyalgia
Rheumatoid Arthritis (M05.xxx/M06.xx) • Autoimmune • Pain caused by inflammation and joint damage • Deformities • Physical activity tolerated
Fibromyalgia (M79.7) • Not autoimmune • Pain experienced within connective tissues and nervous system • No deformities • Physical activity not tolerated
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Documentation Requirements Industry Standard M-E-A-T
M – MONITOR Signs, symptoms, disease progression, disease regression 1.1. MMonitoronitor
E – EVALUATE Proper documentation Test results, medication effectiveness, response requires one to treatment 4.4. Treat of these four 2.2. EEvaluatevaluate elements for A – ASSESS/ADDRESS each diagnosis Ordering tests, discussion, review records, counseling 3.3. AAssess/ssess/ AddressAddress T – TREAT WITH A PLAN OF CARE Medications, therapies, other modalities
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Rheumatoid Arthritis
• Document laterality and extremity ✓ right, left, upper, lower
• Identify single or multiple sites ✓ mono vs poly
• Note severity ✓ mild, moderate, severe
• Document rheumatoid factor (i.e. with or without RA antibody)
• Review and document status annually
• Update current medication and active problem list for treatment
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Provider Validation
Validating patient-reported conditions • Review prior medical records • Diagnostic test results • Consult/specialist reports
Subjective • Document current symptoms • Specify affected joints
Objective • Note any abnormal physical exam findings • Correlate lab/diagnostic imaging results
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Coding Considerations
Assessment • Document RA to highest level of specificity • Link associated conditions or manifestations • Indicate current status • Document details of any organ involvement
Suspected versus Confirmed • Do not code for RA if only suspected and not confirmed
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Remission versus Active Treatment
In Remission: • Should not be described as “history of” • Should be included in assessment, not just problem list/past medical history • Should be documented as “rheumatoid arthritis in remission”
Active Treatment: • Document a specific and concise treatment plan, for example: ✓ Referral to rheumatologist ✓ Laboratory tests and diagnostic imaging ✓ Patient education, including self-management ✓ Date or timeframe for follow-up
Highmark Inc. CONFIDENTIAL AND PROPRIETARY EMR Reminders
• Some EMR systems may populate inaccurate or non-specific descriptions
• Ensure location is identified and correlates with the description populated in the EMR
• Always make sure problem lists are updated with the most current and accurate diagnosis for rheumatoid arthritis
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Related Treatments Treatment Options
Main types • Disease-modifying anti-rheumatic drugs (DMARDs) • Biological treatments • Biosimilars
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Treatment Options
DMARDs: • Methotrexate • Leflunomide • Hydroxychloroquine • Sulfasalazine Biologics: • Abatacept (Orencia) • Adalimumab (Humira) • Entercept (Enbrel) • Infliximab (Remicade) • Tofacitinib (Xeljanz) • Ustekinumab (Stelara)
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Immunodeficiency Status Codes
• D84.821, Immunodeficiency due to drugs: Immunodeficiency due to medications that interfere with the immune system. These medications include but are not limited to immunosuppressant's, corticosteroids and chemotherapy. • D84.822, Immunodeficiency due to external causes: Immunodeficiency caused by external factors such as exposure to radiation therapy or due to bone marrow transplant. • D84.81, Immunodeficiency due to conditions classified elsewhere: Immunocompromised state due to a specific medical condition such as HIV, AIDS, certain cancers and genetic disorders.
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Chart Examples Disclaimer
Any chart examples shown in this section have been redacted to be HIPAA compliant and do not display any type of PHI. They are intended for illustrative purposes only.
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Ambiguous Assessment
These terms do not validate the conditions because they do not confirm the condition exists.
TIP: Review or order lab results in order to confirm the condition and remove wording that leads to ambiguity for the condition.
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Problem List Only
“Visit Diagnoses” that are a listing of conditions require additional M-E-A-T to validate. In this note RA was only documented in this list and did not contain additional support in the encounter note.
Even though the “Plan” indicated “Follows with rheum”, only Fibromyalgia was carried into the assessment and the assumption cannot be made that the rheumatologist also follows the RA for this patient.
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Wrong Diagnosis Selected
In this example, the provider confirmed that the patient has RA, but the diagnosis supported in the Assessment/Plan was fibromyalgia. They are not synonymous with one another but can co-exist and the assigned diagnoses should validate the condition(s) the patient has.
Highmark Inc. CONFIDENTIAL AND PROPRIETARY CMS Documentation Updates Provider Signature
• Electronic signatures require the date and time on the signature line
• Providers must sign notes within 180 days of encounter
Source: Contract-Level RADV Medical Record Reviewer Guidance
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Thank You! Available Resources
HCC University is a provider coding resource on NaviNet. It contains guides to assist with documentation and coding according to CMS documentation standards and ICD-10-CM coding requirements.
1. Log into NaviNet
2. Navigate to the Provider Resource 3 Center
3. Select “Education/Manuals” from the 4 menu bar to expand the selection 4. Select “Coding Education/HCC University” to open the page with corresponding resources
Highmark Inc. CONFIDENTIAL AND PROPRIETARY Questions?
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