Rheumatoid arthritis of left shoulder with involvement of other organs and systems
ICD-10 M05.612 is a billable code used to indicate a diagnosis of rheumatoid arthritis of left shoulder with involvement of other organs and systems.
Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disorder that primarily affects the synovial joints, leading to pain, swelling, and eventual joint destruction. In the case of M05.612, the left shoulder is specifically affected, which can result in significant functional impairment. Anatomically, the shoulder joint comprises the humerus, scapula, and clavicle, with a complex arrangement of ligaments, tendons, and muscles that facilitate a wide range of motion. Pathophysiologically, RA is characterized by the infiltration of immune cells into the synovial membrane, leading to synovitis, cartilage degradation, and bone erosion. Clinically, patients may present with joint stiffness, particularly in the morning, and may experience systemic symptoms such as fatigue and malaise due to the involvement of other organs and systems, including the lungs, heart, and skin. The left shoulder's involvement can lead to limitations in abduction, flexion, and rotation, impacting daily activities and quality of life.
Orthopedic documentation should include imaging studies (e.g., X-rays, MRIs) to assess joint damage, functional assessments to evaluate range of motion, and detailed notes on surgical interventions if applicable.
Common scenarios include surgical interventions such as arthroscopy or joint replacement due to severe joint damage.
Documentation must specify the extent of joint involvement and any surgical history related to the left shoulder.
Rheumatologic documentation should include laboratory tests for inflammatory markers (e.g., ESR, CRP), disease activity scores, and notes on systemic involvement.
Patients may present with flares of RA requiring adjustments in therapy or management of comorbid conditions.
Systemic involvement must be clearly documented, including any extra-articular manifestations such as rheumatoid nodules or lung involvement.
Functional assessments should evaluate mobility, strength, and the need for assistive devices, along with rehabilitation goals.
Rehabilitation scenarios may include post-operative recovery or management of chronic pain and functional limitations.
Documentation should address specific mobility limitations and the impact on daily living activities.
Used for managing joint effusion in the left shoulder due to RA.
Document the joint accessed, the procedure performed, and the indication for the procedure.
Orthopedic and rheumatologic considerations for joint management.
Key documentation includes detailed clinical notes on joint involvement, systemic symptoms, laboratory results indicating inflammation, and any imaging studies that support the diagnosis. It is essential to document the laterality and severity of the condition, as well as any treatments provided.
