Rheumatoid arthritis with rheumatoid factor
Chapter 13:Diseases of the musculoskeletal system
ICD-10 M05 is a billable code used to indicate a diagnosis of rheumatoid arthritis with rheumatoid factor.
Rheumatoid arthritis (RA) is a chronic inflammatory disorder primarily affecting the joints, characterized by synovial inflammation and subsequent joint destruction. The presence of rheumatoid factor (RF) is a serological marker indicating an autoimmune response, where the immune system mistakenly attacks the body's own tissues. Anatomically, RA typically involves the synovial joints, including the hands, wrists, knees, and feet, leading to pain, swelling, and stiffness. Over time, this can result in joint deformities and functional limitations. The pathophysiology involves the infiltration of immune cells into the synovial membrane, leading to the formation of pannus, which erodes cartilage and bone. Clinically, patients may present with symmetrical joint involvement, morning stiffness lasting more than an hour, and systemic symptoms such as fatigue and malaise. Early diagnosis and management are crucial to prevent irreversible joint damage.
Orthopedic documentation should include imaging studies (X-rays, MRIs) to assess joint damage, functional assessments, and treatment plans. Detailed notes on joint range of motion and any surgical interventions are essential.
Common scenarios include joint replacement surgeries, arthroscopic procedures, and management of acute exacerbations of RA.
Joint-specific considerations include documenting the extent of deformities, joint stability, and the impact on mobility.
Rheumatologic documentation must include laboratory results for RF and anti-CCP antibodies, assessments of disease activity (e.g., DAS28), and treatment response.
Scenarios often involve initiation of disease-modifying antirheumatic drugs (DMARDs), biologics, and monitoring for side effects.
Systemic involvement such as rheumatoid nodules, vasculitis, or lung disease must be documented to support the diagnosis.
Functional assessments should evaluate mobility, strength, and the need for assistive devices. Rehabilitation plans must be detailed to reflect the patient's functional goals.
Rehabilitation scenarios may include post-operative recovery from joint surgeries or management of chronic pain.
Mobility limitations should be documented, including the use of walkers or braces, and the impact on daily activities.
Used for joint swelling management in RA patients.
Document joint involved, amount of fluid removed, and any therapeutic agents injected.
Orthopedic and rheumatologic considerations for joint health.
Rheumatoid factor is a key serological marker that helps confirm the diagnosis of RA. Its presence indicates a higher likelihood of severe disease and systemic involvement, which must be documented for accurate coding.
