Rumatoid arthritis, unspecified
ICD-10 M06.9 is a billable code used to indicate a diagnosis of rumatoid arthritis, unspecified.
Rheumatoid arthritis (RA) is a chronic inflammatory disorder primarily affecting the joints, characterized by synovial inflammation and subsequent joint destruction. The pathophysiology involves an autoimmune response where the immune system mistakenly attacks the synovial membrane, leading to pain, swelling, and eventual joint deformity. Clinically, RA typically presents symmetrically, affecting multiple joints, including the hands, wrists, knees, and feet. Patients may experience morning stiffness lasting more than an hour, fatigue, and systemic symptoms such as fever and malaise. Anatomically, the disease affects the synovial joints, where the synovial fluid lubricates the joint surfaces, and inflammation can lead to erosion of cartilage and bone. The chronic nature of RA can result in significant functional limitations and disability, necessitating a multidisciplinary approach to management.
Orthopedic documentation should include imaging studies (X-rays, MRIs) to assess joint damage and functional assessments to evaluate mobility and range of motion.
Common scenarios include surgical interventions such as joint arthroplasty or synovectomy for severe joint damage.
Documentation should specify the joints involved and the severity of damage to guide treatment decisions.
Rheumatologic documentation must include laboratory tests (e.g., rheumatoid factor, anti-CCP antibodies) and assessments of disease activity (e.g., DAS28 score).
Scenarios often involve the initiation or adjustment of disease-modifying antirheumatic drugs (DMARDs) based on disease activity.
Systemic involvement, such as pulmonary or cardiovascular manifestations, should be documented to reflect the full impact of the disease.
Functional assessments should evaluate the patient's ability to perform activities of daily living and mobility limitations.
Rehabilitation scenarios may include physical therapy to improve joint function and reduce pain.
Documentation should address the need for assistive devices and modifications to the home environment.
Used for joint swelling and pain management in RA patients.
Document the joint involved, indication for the procedure, and any therapeutic agents used.
Orthopedic and rheumatologic considerations for joint health and management.
Key documentation includes specific joint involvement, severity of symptoms, laboratory results indicating inflammation, and any systemic manifestations. Consistent updates on treatment response and functional assessments are also crucial.
