What is the best treatment for rheumatoid arthritis?
The “best” treatment for rheumatoid arthritis, a chronic autoimmune disease that causes problems with the joints, may depend on the specific results the patient and his/her physicians hope to achieve.
Is the goal to relieve the symptoms?
To slow down or stop the disease progression and prevent joint or organ damage?
Goals of Treatment
There have been many changes made in the treatment of rheumatoid arthritis over the past 20 years, and more changes are expected. It used to be that a physician would suggest an over-the-counter drug, prescribe medication, or give the patient a corticosteroid shot. Then they would watch and wait until the RA got worse.
In other words, the course of action was to treat the symptoms rather than the disease itself.
Today, a rheumatologist would prescribe a strong medication right away to stop the disease before major damage occurs.
According to the Arthritis Foundation, the main goals of treatment for rheumatoid arthritis (RA) are to:
Stop or reduce the inflammation (bring it to remission) as early as possible
Prevent joint and organ damage
Improve overall well-being and physical function
Decrease any long-term complications
Types of Treatment
According to Johns Hopkins Arthritis Center, there is no known cure for rheumatoid arthritis. However, there are new classes of medications available that improve the outcomes in most patients with RA.
The types of treatment usually include medication, joint stress reduction, physical and occupational therapy, and surgery. Surgery is not performed as often as it once was due to early and aggressive treatment, but it may be needed to correct any joint damage.
Different medications are prescribed for the treatment of RA based on the targeted goal. Some medications relieve the symptoms, while others slow or stop the progression of the disease and prevent joint and organ damage.
Drugs For Symptom Relief
NSAIDs, or nonsteroidal anti-inflammatory drugs, help with the pain and inflammation and include drugs such as ibuprofen, ketoprofen, and naproxen. A prescription will provide a higher dose than what is available over the counter, and the results last longer, as reported by WebMD.
Celecoxib is a type of NSAID called a COX-2 inhibitor. Celecoxib may be prescribed for patients with stomach concerns and is taken orally or as a patch or cream directly to the swollen joint.
Drugs that Slow or Stop Disease Activity
Corticosteroids include such drugs as prednisone, prednisolone, and methylprednisone to control the potentially damaging inflammation and may be taken orally or by injection into the affected joint. These may be taken to get the potentially damaging inflammation under control while waiting for NSAIDs or DMARDs to take effect. However, corticosteroids may only be taken short term and in small doses due to their potential side effects.
DMARDs (disease-modifying anti-rheumatic drugs) are used to change the course of the disease, traditional DMARDs include such medications as methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, cyclophosphamide, and azathioprine. These medications can be provided in the physician’s office as an infusion, or the patient may take it orally or inject it at home.
Biologics are a subset of DMARDs, biologics often work more quickly than the traditional DMARDs. They can slow down, stop, or change the progression of the disease when other treatments are unable to and are provided in a physician’s office by injection or infusion. Since their objective is to target particular steps in the inflammatory process, they are able to avoid destruction of the entire immune system as some other RA treatments do.
JAK inhibitors are a new subcategory of DMARDs that blocks the Janus kinase (JAK) pathways which are part of the body’s immune response. Rather than a biologic, these are small molecules. Tofacitinib and baricitinib are both in this class of drugs and can be taken by mouth.
Biologics and Other DMARDs are now the first line of treatment. Painkillers, steroids, and multiple surgeries are no longer the recommended treatment of choice. Instead, a rheumatologist will begin with a DMARD at the time of diagnosis, and methotrexate is often the drug provided.
If the methotrexate or other DMARD is not doing a good enough job, the rheumatologist may turn to biologic therapy or recommend a combination of methotrexate and a biologic, such as abatacept (Orencia). Using abatacept in combination with methotrexate may be more effective, according to the American College of Rheumatology. However, abatacept should not be used with other biologic drugs.
Other reasons to switch from a DMARD to a biologic may be the patient is pregnant or may become pregnant, or the patient is experiencing side effects from the DMARD, such as liver problems. In these cases, biologics are safer.
The quicker the treatment is started, the sooner the patient’s joint damage can slow down or put the disease into remission. This results in less pain and stiffness. And by using biologics and other DMARDs, surgeries that were once considered routine can be avoided, and the outcome is much better.
Side-Effects of Biologics and Other DMARDs do exist. Both traditional DMARDs and biologics increase the chances of infections, such as pneumonia. And, although rare, there are other potential side effects based on the particular DMARD or biologic prescribed. These side-effects include:
- Skin irritation at the site of injection
- Increased risk of infection, such as tuberculosis
- Increased risk of particular cancers
- Increased risk of heart and neurologic problems
If the patient has a condition such as multiple sclerosis, hepatitis, or heart failure, a biologic may not be advised.
Joint Surgery – Different Types
Fortunately, not everyone with RA requires surgery. It may be something to consider, though, if the RA causes permanent damage that hinders a person’s daily function, mobility, and independence.
The best surgical procedure should be determined by the patient and his/her primary physician, rheumatologist, and an orthopedist. The individual’s goals, rehabilitation ability, and overall medical status will be considered.
Joint surgeries are common in the hips and knees and are also performed on other joints, such as the ankles, shoulders, wrists, and elbows.
There are eight types of joint surgeries performed, according to Arthritis-Health. Nevertheless, the most common types performed in patients with rheumatoid arthritis are joint replacement, arthrodesis, and synovectomy.
- Total Joint Replacement (TJR), also known as Total Joint Arthroplasty. The damaged joint is removed, and an implant made from combinations of metal, plastic, and/or ceramic parts is inserted in its place. This implant mimics the movement of the natural joint.
- Minimally Invasive TJR. Similar to the traditional TJR in that it replaces a damaged joint, but shorter incisions are made and less muscle is cut and reattached.
- Arthrodesis, also known as Fusion. To connect two or more bones in the ankles, wrists, thumbs, fingers or spine, surgeons form one uninterrupted joint by using pins, plates, rods or other hardware. This allows the bones to grow together and lock the joint in place. Sometimes an arthrodesis involves the use of bone grafts from the patient’s own pelvis.
- Synovectomy. The synovium, or lining of the joints, can become inflamed or grow too much in people with inflammatory arthritis. This damages the surrounding cartilage and joints. Surgeons perform open or arthroscopic surgery to remove most or all of the affected synovium.
- Arthroscopy. Small incisions, specialized instruments, and a tiny camera are used to fix tears in the soft tissues surrounding the knee, hip, shoulder, and other joints; damaged cartilage is repaired; and broken, detached cartilage pieces are removed.
- Joint resurfacing. When the knee is involved, it may also be referred to as unicompartmental or partial knee replacement. Surgeons replace just one of the three compartments of the knee with an implant. These include the medial (inside), lateral (outside) or patellofemoral (front) compartment. When the hip is involved, surgeons take out the arthritic cartilage and acetabulum (hip socket) and put in place a metal cup before reshaping the hip ball and covering it with a metal, rounded prosthesis.The patient’s natural femoral head is preserved.
- Osteotomy. Near a damaged joint, a bone is cut or removed, or a wedge of bone is added. For example, in the knee, this procedure takes the weight off the arthritis-damaged area and places it on the undamaged area. An osteotomy of the hip is often performed to correct hip dysplasia that happens early in life.
- Joint Revision. An implant that has failed, become worn, or infected, is surgically replaced with a new implant.
CPT codes related to joint procedures are found in the Surgery/Musculoskeletal System section. This section is further classified by general surgical procedures, surgical procedures based on the anatomic site (pelvis and hip joint, femur and knee joint, shoulder, etc.), application of casts and strapping, and endoscopy/arthroscopy procedures.
The individual categories for surgical procedures based on the anatomic site are further broken down by the treatment approach.
Although joint procedures are performed on various joints in the body, for the sake of understanding, we will discuss CPT codes related to the hip joint. This knowledge can then be transferred to coding joint procedures on other body parts.
Coding for Hip Joint Procedures
Surgical procedures on the pelvis and hip joint are broken down as follows:
- 26990‑27036, Incision Procedures on the Pelvis and Hip Joint
- 27040‑27080, Excision Procedures on the Pelvis and Hip Joint
- 27086-27096, Introduction or Removal Procedures on the Pelvis and Hip Joint
- 27097‑27187, Repair, Revision, and/or Reconstruction Procedures on the Pelvis and Hip Joint
- 27197‑27269, Fracture and/or Dislocation Procedures on the Pelvis and Hip Joint
- 27275‑27275, Manipulation Procedures on the Pelvis and Hip Joint
- 27279‑27286, Arthrodesis Procedures on the Pelvis and Hip Joint
- 27290‑27295, Amputation Procedures on the Pelvis and Hip Joint
- 27299‑27299, Other Procedures on the Pelvis or Hip Joint
To find the CPT codes for joint procedures, you can look in the Index under the treatment approach, such as Arthrodesis, and the joint, such as Hip Joint. Or you can look under the anatomic site, such as Hip, and the treatment approach, such as Arthrodesis. The correct code can then be verified in the Tabular.
Hip arthroplasties are reported with codes from the Repair, Revision, and/or Reconstruction Procedures on the Pelvis and Hip Joint category (27097-27187). An arthroplasty refers to the surgical repair of a joint for pain relief, function restoration, or movement restoration. The specific codes include:
- 27125, Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)
- 27130, Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft
- 27132, Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft
- 27134, Revision of total hip arthroplasty; both components, with or without autograft or allograft
- 27137, Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft
- 27138, Revision of total hip arthroplasty; femoral component only, with or without allograft
The documentation should indicate whether the arthroplasty is an initial procedure or a revision. It should also indicate if it is a total (27130) or partial (27125) replacement and, if partial, the component that is being replaced.
Hemiarthroplasties (partial) are usually performed for hip fractures rather than for rheumatoid arthritis. Hence, if the patient is diagnosed with rheumatoid arthritis, code 27130 would usually be assigned for a total hip arthroplasty.
Whether the procedure performed is a total hip replacement or a minimally invasive total joint replacement, CPT 27130 would be assigned.
If the procedure is a revision (27134, 27137, 27138), the component or components should be specified. A revision of both the acetabular and femoral components is assigned 27134; a revision of the acetabular component of the total hip prosthesis only is assigned 27137; a revision of the femoral component only is assigned 27138.
If it is a conversion from, say, a fused hip (arthrodesis) years ago to a total hip arthroplasty today, it should be documented, and the coder should assign CPT 27132.
Hip arthrodeses are reported with codes from the Arthrodesis Procedures on the Pelvis and Hip Joint (27279-27286) and include:
- 27284, Arthrodesis, hip joint (including obtaining graft)
- 27286, Arthrodesis, hip joint (including obtaining graft); with subtrochanteric osteotomy
This procedure has been mostly replaced with the hip arthroplasty. However, it may be done in young people or those who have had an unsuccessful hip replacement. The documentation should specify if the hip arthrodesis included a subtrochanteric osteotomy in order to assign 27286.
Hip synovectomies can be performed as an open procedure or with an arthroscope. An open synovectomy of the hip is considered major surgery and often requires general anesthesia. A medical term ending in -otomy refers to an open procedure.
The CPT code for this open procedure is found in the Excision Procedures on the Pelvis and Hip Joint subsection (27040-27080) and is reported with:
27054, Arthrotomy with synovectomy, hip joint
An arthroscopic synovectomy of the hip is a closed procedure. There is no surgical opening made in the body. Instead, small incisions are made through a scope. A medical term ending in -oscopy refers to a closed procedure.
The CPT code for this arthroscopic procedure is located in the Endoscopy/Arthroscopy Procedures on the Musculoskeletal System subsection (29800-29999) and under the Arthroscopy, hip, surgical category (29861-29916). This specific procedure is reported with:
29863, Arthroscopy, hip, surgical; with synovectomy
Hip resurfacing procedures do not have their own specific code. According to the National Institutes of Health and the AAPC Forum, the CPT code for the total hip arthroplasty (27130) should be assigned with Modifier 22 appended to the CPT code to indicate extra work was involved. By using the modifier, the provider is also more likely to receive reimbursement.
Another option is to use a HCPCS code for private payors that accept it:
S2118, Metal-on-metal total hip resurfacing, including acetabular and femoral components
Finally, there is an unlisted code that may be accepted:
27299, Unlisted procedure, pelvis or hip joint
I would check with the individual insurance company to determine their requirements.
Hip osteotomies are, as mentioned above, used mostly to treat hip dysplasia rather than rheumatoid arthritis. The most common type of osteotomy performed for hip dysplasia is the periacetabular osteotomy. This procedure involves the surgeon performing multiple cuts (osteotomies) in the three bones of the pelvis, according to the Denver Clinic.
In CPT, there are many orthopedic procedures with no specific CPT code, and a periacetabular osteotomy is one of them. According to the American Academy of Orthopaedic Surgeons, the following code should be assigned:
27299, Unlisted procedure, pelvis or hip joint
Otherwise, there is a HCPCS code that some payors recognize:
S2115, Osteotomy, periacetabular, with internal fixation
2 more things to keep in mind:
1. When coding for orthopedic procedures, it is important to use the appropriate modifiers to show laterality when applicable, such as RT (right), LT (left), 50 (bilateral), F1-F9 (fingers), and TA-T9 (toes).
2. When a physician implants a prosthetic device during a joint replacement, a HCPCS Level II code is also needed: C1776, Joint device (implantable).
Coding for Other Joint Procedures
When coding for surgical procedures on other joints, such as the shoulder or knee, go to the Surgery/Musculoskeletal System section and the respective subsection for that anatomic site.
Looking up these procedures in the CPT coding manual Index is the same process as for the hip joint procedures. Locate the treatment approach first, such as Arthroplasty, and then the body location, such as Ankle, Elbow, Knee, Wrist, etc. This will refer you to a code(s) that you can then verify in the Tabular.
Or start with the name of the joint, such as Shoulder Joint, and then the treatment, such as Arthroplasty. You can then verify the codes in the Tabular.
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