ACR Proposes New ICD-10 Code to Capture ‘Pre-RA’

On Sept. 13, the ACR and Kevin D. Deane, MD, PhD, rheumatologist at the University of Colorado, Aurora, presented a proposal to create a new clinical code to recognize “pre-rheumatoid arthritis” to the International Classification of Diseases Coordination & Maintenance Committee (ICD-10 C&M) at the Centers for Medicare & Medicaid Services (CMS).

The International Classification of Diseases 10th Revision, or ICD-10-CM, is the Health Insurance Portability & Accountability Act (HIPAA) code set standard for reporting diagnoses in all healthcare settings. ICD-10-CM is a U.S. clinical modification of the World Health Organization’s ICD-10. These codes help ensure the accuracy, protection and accessibility of health information.

Twice each year, organizations have the opportunity to present diagnosis code proposals to the ICD-10 C&M for consideration. This federal committee, which includes the CMS and the Centers for Disease Control & Prevention’s (CDC) National Center for Health Statistics (NCHS), focuses on the clinical issues for a condition, procedure or technology and is responsible for approving ICD code changes, diagnosis errata, addenda and modifications.

The ACR’s code change request proposes a new code and definition for pre-rheumatoid arthritis (pre-RA), a condition in which an individual may exhibit RA-related autoantibodies without the clinical condition (i.e., inflammatory arthritis) of RA. The proposed new code and definition is: R76.81 “Abnormal rheumatoid arthritis-related immunologic findings without current or prior diagnosis of clinically apparent inflammatory arthritis.”

Rationale

The code proposal included a rationale for why a pre-RA code is needed.

RA is a well-known autoimmune condition that is characterized by the presence of inflammatory arthritis. Up to 80% of individuals with RA may also have abnormalities in circulating biomarkers, including but not limited to the autoantibodies rheumatoid factor (RF) and antibodies to cyclic citrullinated proteins (CCP).

The current paradigm for the diagnosis and treatment of RA is for a clinician to identify joint findings that are determined to be clinically apparent IA, diagnose the condition as RA and initiate treatment. This is the typical clinical situation in which the existing ICD-10 codes for RA (e.g., M60.XXX, M50.XXX) are applied.

However, it is now well-established that RA-related immunologic tests such as RF and CCP can be present in individuals in the absence of and prior to the appearance of inflammatory arthritis and are predictive of future onset of clinical RA—a period that can be termed “pre-RA.” Further, individuals who have abnormal RA-related immunologic tests without inflammatory arthritis are being identified in growing numbers in clinical care.

Medically appropriate counseling approaches are currently available and can help individuals in this pre-RA state gain awareness of RA, its symptoms, the importance of medical follow-up to watch for the development of treatable inflammatory arthritis, and lifestyle changes (e.g., smoking cessation) that may lower their risk for developing RA. In addition, the predictive ability of RF and anti-CCP for future clinical RA has underpinned multiple clinical observational studies and prevention trials in RA, and it is expected that there soon will be approved pharmacologic therapies for RA prevention.

Importantly, although existing ICD-10 codes can be used to designate clinical RA as well as RF and anti-CCP positivity, there is not currently a clear way in the existing ICD-10 system to designate individuals who may exhibit RA-related biomarkers but do not have clinically apparent inflammatory arthritis. As such, the introduction of a new code to accurately designate an individual who has abnormal RA-related immunologic tests will facilitate clinical designation and care of these individuals, as well as facilitate clinical research.

Next Steps

The ACR presented the case for this new code to the CDC and received some initial feedback that included shortening the term, as well as including the specific laboratory tests that would qualify this code. A suggested revision is: “Anti-cyclic citrullinated peptide antibody (anti-CCP) and/or rheumatoid factor (RF) positivity without a current or prior diagnosis of rheumatoid arthritis.”

Final decisions on code revisions are made through a clearance process within the Department of Health & Human Services. The ACR expects to receive formal feedback around mid-November, after which we will address any comments and plan to move forward with finalizing this new code.

Questions on ICD-10 or the code change proposal can be sent to Antanya Chung at [email protected] or [email protected].