November 15, 2018
Rheumatoid arthritis (RA) is an autoimmune disease in which the immune system attacks healthy joints. Inflammation causes the destruction of joints and can also damage organs. Anyone can get RA, but it occurs more often in women and is most common in older people. Disease modifying anti-rheumatic drugs (DMARDs) can help preserve function and prevent further damage to joints.
The Healthcare Effectiveness Data and Information Set (HEDIS) measures the percentage of patients 18 years and older who’re diagnosed with RA and filled at least one ambulatory prescription for a DMARD in the current measurement year. At times, providers code RA on a claim when the patient doesn’t have a definitive diagnosis.
When a provider codes RA on a claim without a definitive diagnosis, it triggers Premera to look for pharmacy claims evidence that a DMARD prescription was filled. When we identify that a DMARD has not been filled for a member, we may reach out to you for more information.
Ensure accurate diagnosis and coding by following these guidelines:
- Only code claims with a diagnosis of RA when it is confirmed through appropriate testing.
- A diagnosis of osteoarthritis or joint pain should not be coded as RA.
- Avoid coding diagnoses using terms such as “probable, suspected, questionable, rule out, working diagnosis” or similar terms indicating uncertainty.
- Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a definitive diagnosis hasn’t been confirmed.
For patients who do have a definitive diagnosis of RA, consider prescribing a DMARD. DMARDs can modify the disease course of RA by limiting the progression of bony erosions and reducing inflammation and long-term structural damage. DMARDs can improve function for patients with RA.
Learn more about who’s included in the measure and the new exclusion and frailty codes.
For more information and/or questions regarding this or any other HEDIS measure, contact ProviderClinicalConsulting@Premera.com.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).