Documenting and Coding Ankylosing Spondylitis

Documenting and Coding Ankylosing Spondylitis

Ankylosing spondylitis is form of arthritis that primarily affects the spine. The article details the documentation and coding guidelines for the same.

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Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects your spine causing severe inflammation of the vertebrae. The condition is characterized by back pain and stiffness that normally appear during adolescence or early adulthood. Over time, back movement gradually becomes limited as the bones of the spine (vertebrae) fuse together, resulting in a rigid spine. These changes may be mild or severe, and may lead to a stooped-over posture. There is no specific cure for ankylosing spondylitis, but treatments can lessen your symptoms and possibly slow down the progression of the disease. Early diagnosis and treatment can help control the pain and stiffness associated with the condition and may prevent significant deformity. Outsourcing medical billing tasks will help in accurate clinical documentation of this disorder and enable physicians to focus more on patient care.

It is estimated that this condition is around three times more common in men than in women. Signs and symptoms in most cases begin in early adulthood. The condition typically starts in the joints between your spine and pelvis, but it may spread up your spine to your neck. In some cases, it can affect other parts of the body including your shoulders, hips, knees or eyes.

Causes and Symptoms The exact cause of ankylosing spondylitis is currently unknown, although genetic factors seem to play an active role. One risk factor for AS is having a family history of the disease.

The most common symptom of this condition is pain and stiffness in your lower back and hips (experienced by people in the morning and at night and after periods of inactivity).

Over time, symptoms might worsen, improve or stop at irregular intervals. The most common areas affected include - sacroiliac joint, vertebrae in your lower back, cartilage between your breastbone and ribs, and hip and shoulder joints. Some common signs and symptoms of AS include 

Poor posture or stooped shoulders

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Mild eye inflammation

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Low-grade fever

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Loss of appetite

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Inflammation of the bowels

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Fatigue

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Early morning stiffness

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Anemia or low iron

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Heart valve inflammation

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Weight loss

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Reduced lung function

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Neck pain

How Is AS Diagnosed and Treated?

Diagnosing Ankylosing spondylitis is quite difficult as it is a highly variable disease with a wide range of symptoms. In most cases, individuals may only experience episodes of mild back pain, while others may have severe chronic pain accompanied by stiffness in the spine affecting their posture and daily activities.

Initial diagnosis of this condition begins with a detailed physical examination. Physicians may ask patients to bend in different directions to test their range-of-motion. They may try to evaluate pain by pressing on specific portions of the pelvis or by moving your legs into a particular position. Imaging tests like X-rays and MRI scans may be done to check for any possible changes in your joints and bones. In addition, blood tests may be conducted to check for markers of inflammation and the specific factors that possibly cause these infections. Correct and timely treatment can help reduce symptoms and also slow or even stop possible complications such as bone deformity. Treatment options include medications and physical therapy exercises.

Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen help manage pain and inflammation. In addition, tumor necrosis factor (TNF) inhibitors are used to block inflammation triggers in your body. These drugs are directly administered by injecting the medication under the skin or through an intravenous line. These drugs help prevent inflammation and ease joint pain and stiffness. Physical therapy exercises help improve strength and flexibility. Surgery will be recommended as a last resort if you have chronic pain or joint damage or if your hip joint gets severely damaged that it needs to be replaced.

Rheumatology medical coding involves using the specific ICD-10 diagnosis codes for reporting ankylosing spondylitis on your medical claims. ICD-10-CM codes used to indicate a diagnosis of this condition include 

M45 - Ankylosing spondylitis

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M45.0 - Ankylosing spondylitis of multiple sites in spine

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M45.1 - Ankylosing spondylitis of occipito-atlanto-axial region

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M45.2 - Ankylosing spondylitis of cervical region

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M45.3 - Ankylosing spondylitis of cervicothoracic region

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M45.4 - Ankylosing spondylitis of thoracic region

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M45.5 - Ankylosing spondylitis of thoracolumbar region

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M45.6 - Ankylosing spondylitis lumbar region

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M45.7 - Ankylosing spondylitis of lumbosacral region

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M45.8 - Ankylosing spondylitis sacral and sacrococcygeal region

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M45.9 - Ankylosing spondylitis of unspecified sites in spine

Reports suggest that about 90 percent of people who develop AS have a gene called HLAB27. People with this gene are at increased risk of developing ankylosing spondylitis.

However, having this gene does not necessarily mean that they may develop this condition.

Medical coding for Ankylosing Spondylitis (AS) can be challenging. For accurate and timely medical billing and claims submission, rheumatology practices can outsource their medical coding tasks to a professional medical billing company which offers the services of AAPCcertified coding specialists.

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918-221-7769