714

People joke about Friday the 13th, but you never see Friday the 714th.  Although some office buildings have a 13th floor, you’ll never see a skyscraper with 714 floors.  This is not (as some believe) due to engineering difficulties of such a tall building; it’s because 714 is such an awful number, nobody wants anywhere near it.  If you’re invited anywhere on July 14, play it safe and stay home.

I nominate 714 as a credible replacement for 13 as an unlucky number. 

When a doctor submits claims to an insurer, included are procedure codes and diagnosis codes.  The ICD-9 codes beginning with 714 are for “rheumatoid arthritis and other inflammatory polyarthropathies.” 

  • 714.0 Rheumatoid arthritis
  • 714.1 Felty’s syndrome
  • 714.2 Other rheumatoid arthritis with visceral or systemic involvement
  • 714.3  Juvenile chronic polyarthritis
  • 714.4 Chronic post-rheumatic arthropathy/Jaccoud’s syndrome
  • 714.8 Other
  • 714.9 Unspecified

For a long time, my rheumatologist used 719.49 (joint pain, multiple sites), not wanting to give my insurance company that RA label until she was positive.  Eventually, though, she switched to 714.0.

When the doctor told my daughter that her diagnosis is “enthesitis” and she does not have arthritis, I assumed that there’s an ICD-9 code for that.  One would think that “not arthritis,” would use an ICD-9 code not beginning with 714.  I was wrong.

The nutritionist, the occupational therapist, and the physical therapist ALL billed my daughter’s last appointment with an ICD-9 code of 714.32!  The rheumatologist’s claim still hasn’t been processed, so I don’t have that EOB, but since she wrote the referral for the other appointments, one would assume that’s where they got that particular diagnosis.

  • 714.30 chronic juvenile polyarthritis, unspecified
  • 714.31 chronic polyarticular juvenile rheumatoid arthritis
  • 714.32  chronic pauciarticular juvenile rheumatoid arthritis
  • 714.33 chronic monoarticular juvenile rheumatoid arthritis

My daughter has been specifically told that this is just enthesitis, not JRA.

  • If it’s not JRA, don’t tell the insurance company that it is.  This makes a huge impact on the rest of her life.
  • If it is JRA, why were we not told?  Why are we screwing around with NSAIDs instead of a DMARD?

Why pauciarticular?

  • Pauciarticular means 4 or fewer joints involved for the first six months.  My daughter has had many joints involved.
  • Pauciarticular does not tend to be symmetrical.  My daughter’s joint pain is symmetrical.
  • Pauciarticular usually does not involve the hips.  Hips were my daughter’s first symptom.
  • Pauciarticular means increased risk for eye involvement.  My daughter has not been given a referral to an ophtholmologist.

I don’t understand how her problem qualifies as 714.32.  Apparently it is time for me to learn a lot more about the different types of arthritis.  I think, for my birthday, I’m getting myself a 714-page rheumatology textbook.

More on EMR’s next week.
Then a follow-up post to this one – once I regroup.

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6 thoughts on “714

  1. This is an important issue. I see this in my work every day. Medical providers have billing specialist that will bill using the code that will justify the treatment and allow for the highest amount in reimbursement. The patients actual ailment matters very little. So, they will treat you for what they think you have and bill for what pays the most. You can imagine that this is important with our ever increasing health care costs. I feel it is akin to Arthur Anderson massaging the figures. This coding practice is also the why we see an increase in the number of medical facilities are being sued for Medicare fraud.

  2. Gretel is probably right. And about it keeping health care costs for the country going up, up, up.

    Socks, I’m sorry to hear about this diagnosis. Was hoping it would be more benign or short-lived. Wishing you and Dau the best in getting it sorted out and treated right.

    I may be adult RA, but my very first symptoms were enthesitis related and my flares tend to be that way. Some sites do list enthesitis as a symptom of adult RA.

  3. Hensel, I’ve phoned the clinic and left a message explaining the situation and asking for clarification of the diagnosis, pointing out that my daughter is uninsurable in the future if she’s diagnosed with arthritis so I’d like to be mighty sure that’s what she has before slapping that label on her.

    Chelsea, the only place I’ve seen mention of enthesitis is in spondyloarthropathy discussions. Do you have links to info tying it specifically to RA? Most of my symptoms are tendon-related now, which is why I’m so insistent that we figure out what’s going on with my kid. I don’t believe (after all these years) this is going to go away on its own. The NSAIDs help, but not enough. I’m stuck between wanting my daughter treated, but not wanting her diagnosed. If that makes any sense.

    • I do understand about treatment vs. diagnosis and know it’s a tough spot to be in. And do understand about the “labeled” and insurance problem. She might have more treatment options with the rheumatoid dx than something more restrictive that has less approved meds though, making it easier should she need something off label, or that might not make a difference. I wouldn’t want to put my kid on dmards or biologics if I didn’t have to.

      The aboutarthritis.com site lists ensethitis as part of RA:

      “Among others, conditions associated with enthesitis include:

      •Achilles tendinitis
      •reactive arthritis
      •rheumatoid arthritis
      •osteoarthritis
      •diffuse idiopathic skeletal hyperostosis (DISH)”
      http://arthritis.about.com/od/arthritissignssymptoms/f/enthesitis.htm

      • Thank you.
        I talked to a nurse at the doctor’s office. They did NOT use 714.32. They used icd9 code 726.5, which is enthesopathy.

        I then phoned the insurance company, who gave me a list of ICD-9 codes used on the bill for the date in question. 726.5 isn’t among them, but 714.32 is.

        I’ll be calling the billing department next. It’s one thing to pull out all the stops and bill for every single thing possible, it’s entirely different to change a diagnosis. I don’t have a problem with people being paid fairly for their work; I do have a problem with fraud.

  4. Ultrasonography for detecting enthesitis in juvenile idiopathic arthritis
    Thursday, February 10, 2011, 11:08:19 AM | Sandrine Jousse-Joulin
    Abstract
    Objective:
    Enthesitis is a major feature of juvenile idiopathic arthritis (JIA) but is difficult to diagnose clinically. Our objective was to compare the accuracy of ultrasonography with power Doppler (US-PD) versus clinical examination for diagnosing enthesitis in patients with JIA and healthy controls.

    Methods:
    26 consecutive patients with JIA and 41 healthy volunteers underwent standardized clinical and US-PD examinations of five entheseal sites (proximal and distal quadricepital tendon insertions, Achilles tendon, and plantar fascia). US-PD reproducibility was evaluated. US-PD enthesitis was defined as a power Doppler signal at the enthesis insertion. Bursitis, erosions, and cartilage vascularization were recorded.

    Results:
    In the JIA group, 27 (12.5%) of the entheseal sites exhibited clinical enthesitis (distal patellar ligament, 45% of cases) and 20 (10.5%) exhibited US-PD enthesitis (distal patellar tendon, 30%), including 10 (50%) clinically normal sites. US-PD enthesitis was found in several patients with oligoarthritis or polyarthritis. Clinical enthesitis (p<0.0001) and HLA-B27-positive (p=0.05) status were significantly associated with US-PD enthesitis. Erosion and bursitis, but not tendon thickening, were associated with US-PD enthesitis. US-PD enthesitis was not found at any of the 410 entheseal sites in controls; grade 1 cartilage vascularization was noted at 6% of control sites.

    Conclusion:
    Enthesitis is a rare phenomenon in JIA. Clinically silent enthesitis are detected by US-PD and can be found in JIA categories other than enthesitis-related arthritis. Tendon thickening and cartilage vascularization can be detected in healthy controls. These findings may have implications for patient classification of the use of US-PD.
    http://onlinelibrary.wiley.com/doi/10.1002/acr.20444/abstract;jsessionid=09E1BFE76078282DC242C399CAB60E57.d02t01

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