Rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder
ICD-10 M05.419 is a billable code used to indicate a diagnosis of rheumatoid myopathy with rheumatoid arthritis of unspecified shoulder.
Rheumatoid myopathy is a complication of rheumatoid arthritis (RA) characterized by muscle weakness and pain due to inflammation of muscle tissue. In this case, it is associated with rheumatoid arthritis affecting the shoulder region, which is not specified as left or right. The shoulder joint comprises the glenohumeral joint, acromioclavicular joint, and scapulothoracic articulation, all of which can be affected by RA. Clinically, patients may present with shoulder pain, limited range of motion, and muscle weakness, impacting daily activities and overall quality of life. The pathophysiology involves autoimmune-mediated inflammation leading to synovitis, which can extend to adjacent muscle tissues, causing myopathy. Diagnosis is typically supported by clinical examination, serological tests for rheumatoid factor and anti-CCP antibodies, and imaging studies to assess joint involvement.
Orthopedic documentation should include imaging studies (X-rays, MRI) to assess joint integrity and functional assessments to evaluate range of motion and strength.
Patients may present with shoulder pain and limited mobility, requiring surgical intervention such as arthroscopy or joint replacement.
Documentation must detail the severity of joint involvement and any surgical history related to the shoulder.
Rheumatologic documentation should include lab results for inflammatory markers (ESR, CRP) and disease activity scores (DAS28) to assess the severity of RA.
Patients may experience flares of RA leading to exacerbated myopathy, necessitating adjustments in treatment regimens.
Systemic involvement should be documented, including any extra-articular manifestations of RA.
Functional assessments should evaluate the patient's ability to perform activities of daily living and any rehabilitation needs.
Patients may require physical therapy to improve mobility and strength post-inflammation.
Documentation should address mobility limitations and the need for assistive devices.
Used for rehabilitation of shoulder function post-myopathy diagnosis.
Document specific exercises performed and patient progress.
Physical therapy documentation should focus on functional outcomes.
Specifying laterality is crucial for accurate coding and treatment planning, as it affects the management approach and potential surgical interventions.
