Take the challenge. CPT: 99203 This encounter is coded as 99203, because it included: History—The history of present illness was extended. The review of systems was complete, and the past medical, family and social were documented. This makes the history comprehensive. Examination—Expanded detailed. Medical decision making—The diagnosis was a new problem with no additional workup…
Rheumatology March Coding Corner Question: Pediatric Rheumatology Consult
A 13-year-old black male, described by his mother as a very active and energetic child, is referred to a pediatric rheumatologist. His chief complaint is muscle pain in both legs, which he has experienced for the past three weeks. His mother is a patient of an adult rheumatologist at this clinic and is quite concerned….
Quality Measures Used to Assess Care, Improve Outcomes in Children, Adults with Rheumatic Diseases
WASHINGTON, D.C.—In a session during the 2016 ACR/ARHP Annual Meeting, aptly called Quality Measures and Quality of Care I, a panel of experts presented information on a number of programs underway in rheumatology using quality measures to both assess and improve patient outcomes. Leading off were two presentations on programs using quality measures to improve…
New Findings on Rheumatic Drug Therapies among Patients with Ankylosing Spondylitis, Gout, SLE
WASHINGTON, D.C.—Taking high-dose non-steroidal anti-inflammatory drugs (NSAIDs) with a TNF inhibitor as an ankylosing spondylitis (AS) patient is linked with a 61% decrease in the chances your disease will progress, suggesting there may be a synergy when the drugs are used together, according to a longitudinal observational study from researchers at the University of California,…
Pain Management Research Sheds Light on Postsurgical Pain Sensitization, Opioid Risks, Nondrug Interventions
WASHINGTON, D.C.—Successful management of pain remains a challenge for rheumatologists. Five research abstracts presented at the 2016 ACR/ARHP Annual Meeting in a session titled Pain—Basic and Clinical Aspects offered new insights on pain sensitization, and the risks and effects of various pain therapies. Knee Pain After Surgery Can we predict which patients will have longer-term…
Factors that Influence Biologic Therapy Choices for Patients with Rheumatoid Arthritis
Recent research analyzed factors influencing the selection of the first-line biologic medications and the real-life factors that lead to switching from those medications to other biologics in treating rheumatoid arthritis (RA). The study compared the use of abatacept and tocilizumab with a tumor necrosis factor alpha inhibitor (TNFi).1,2 Participants were enrolled in the Lombardy Rheumatology…
Environmental Factors in Pediatric Systemic Autoimmune Diseases
Systemic autoimmune diseases are thought to result from immune dysregulation in genetically susceptible individuals who were exposed to environmental risk factors. Many studies have identified genetic risk factors for these diseases, but concordance rates among monozygotic twins are 25–40%, suggesting that nonheritable environmental factors play a more prominent role.1,2 Through carefully conducted epidemiologic and other…
Metagenomic Deep Sequencing for Uveitis Enhances Traditional Diagnostic Testing
Throughout their training and practice, physicians become adept at pattern recognition as a means to efficiently connect and synthesize seemingly disparate laboratory, physical exam, and radiologic and historical findings into a coherent theory for what likely ails the patient sitting in front of them. This inductive method of reasoning is necessary because, based on these…
Undercoding Is Not an Audit-Proof Strategy in Medical Documentation
Overcoding is a common term used when discussing fraud and abuse in reporting procedures and services not supported by the actual work performed. Alternatively, undercoding—or failing to report the full extent of services or procedures provided—is an equally unsound practice and a compliance risk. In the world of quality reporting, undercoding can have damaging effects…
How to Diagnose Antisynthetase Syndrome
Antisynthetase syndrome (AS) is strongly associated with the presence of antibodies to aminoacyl-transfer RNA (tRNA) synthetases (ARSs) that are implicated in the pathogenesis of myositis and interstitial lung disease (ILD). Antibodies against eight antisynthetases have been identified and are detected in 16–26% of patients with idiopathic inflammatory myopathies (IIM).1 Serum assays for five of these…
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