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ICD-10 Guide
ICD-10 CodesM05.36

M05.36

Billable

Rheumatoid heart disease with rheumatoid arthritis of knee

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/12/2025

Code Description

ICD-10 M05.36 is a billable code used to indicate a diagnosis of rheumatoid heart disease with rheumatoid arthritis of knee.

Key Diagnostic Point:

Rheumatoid heart disease (RHD) is a complication of rheumatoid arthritis (RA) characterized by inflammation of the heart tissues, which can lead to pericarditis, myocarditis, and valvular heart disease. The knee joint, a hinge joint formed by the femur, tibia, and patella, is commonly affected in RA, leading to synovitis, joint effusion, and pain. Clinically, patients may present with joint swelling, stiffness, and reduced range of motion in the knee, alongside systemic symptoms of RHD such as chest pain, dyspnea, and fatigue. The interplay between systemic inflammation from RA and localized joint pathology necessitates a comprehensive approach to diagnosis and management, including imaging studies and laboratory tests to assess inflammatory markers and cardiac function.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Involvement of multiple body systems (musculoskeletal and cardiovascular)
  • Need for detailed documentation of joint involvement and systemic effects
  • Potential for overlapping symptoms with other conditions
  • Variability in disease presentation and progression

Audit Risk Factors

  • Inadequate documentation of joint involvement and severity
  • Failure to capture systemic manifestations of RHD
  • Misclassification of the primary diagnosis versus secondary conditions
  • Lack of clarity in treatment plans and outcomes

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed imaging reports (X-rays, MRIs) and functional assessments (range of motion, strength testing) are essential for orthopedic documentation.

Common Clinical Scenarios

Patients may require surgical interventions such as arthroscopy or joint replacement due to severe knee damage.

Billing Considerations

Documenting the extent of joint damage and functional limitations is crucial for treatment planning.

Rheumatology

Documentation Requirements

Rheumatologic documentation should include laboratory results (e.g., rheumatoid factor, anti-CCP antibodies) and assessments of disease activity (e.g., DAS28 score).

Common Clinical Scenarios

Management of RA flares and monitoring of cardiac involvement are common scenarios.

Billing Considerations

Systemic involvement must be documented, including any cardiovascular assessments.

Physical Medicine

Documentation Requirements

Functional assessments focusing on mobility, pain levels, and rehabilitation goals are necessary.

Common Clinical Scenarios

Rehabilitation following joint surgery or management of chronic pain syndromes.

Billing Considerations

Assessing the need for assistive devices and home modifications is important for patient care.

Coding Guidelines

Inclusion Criteria

Use M05.36 When
  • Coders must ensure accurate documentation of laterality (right, left, bilateral) and severity (mild, moderate, severe) of both the knee arthritis and heart disease
  • Encounter type (initial, follow
  • up) also impacts coding

Exclusion Criteria

Do NOT use M05.36 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

20610CPT Code

Arthrocentesis, aspiration and/or injection into a major joint or bursa

Clinical Scenario

Used for knee joint effusion management in RA patients.

Documentation Requirements

Document the joint involved, procedure details, and patient response.

Specialty Considerations

Orthopedic and rheumatologic considerations for joint management.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for greater specificity in coding musculoskeletal conditions, enabling better tracking of comorbidities like rheumatoid heart disease alongside joint disorders.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for greater specificity in coding musculoskeletal conditions, enabling better tracking of comorbidities like rheumatoid heart disease alongside joint disorders.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for greater specificity in coding musculoskeletal conditions, enabling better tracking of comorbidities like rheumatoid heart disease alongside joint disorders.

Resources

Clinical References

  • •
    American College of Rheumatology Guidelines

Coding & Billing References

  • •
    American College of Rheumatology Guidelines

Frequently Asked Questions

What are the key documentation requirements for coding M05.36?

Key documentation includes detailed descriptions of joint involvement, systemic symptoms, imaging results, and treatment plans. It is essential to capture both the musculoskeletal and cardiovascular aspects of the patient's condition.