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2025 ICD-10-CM code M06.9

Rheumatoid arthritis, unspecified.

Use an external cause code following the code for the musculoskeletal condition, if applicable, to identify the cause. Excludes arthropathic psoriasis (L40.5-), certain conditions originating in the perinatal period (P04-P96), certain infectious and parasitic diseases (A00-B99), compartment syndrome (traumatic) (T79.A-), complications of pregnancy, childbirth and the puerperium (O00-O9A), congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99), endocrine, nutritional and metabolic diseases (E00-E88), injury, poisoning and certain other consequences of external causes (S00-T88), neoplasms (C00-D49), symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R94).

Medical necessity for treatment is established by the presence of signs, symptoms, and laboratory findings consistent with rheumatoid arthritis. The specific treatment modalities are justified based on the severity of the disease and the patient's individual needs.

Diagnosis of unspecified rheumatoid arthritis involves patient history, physical examination, imaging (X-rays), lab tests (rheumatoid factor, antibodies, inflammatory markers), and synovial fluid analysis. Treatment includes NSAIDs, corticosteroids, DMARDs, and biologic response modifiers.

In simple words: RA is a disease where the body's immune system attacks its own joints, causing pain, swelling, stiffness, and sometimes damage. This code is used when the doctor doesn't specify what kind of RA it is.

Rheumatoid arthritis is an autoimmune disorder that causes inflammation of the joints. This code specifies that the type of rheumatoid arthritis is not specified.

Example 1: A 45-year-old female presents with joint pain, morning stiffness, and swelling in multiple joints. Blood tests reveal the presence of rheumatoid factor and elevated inflammatory markers. The physician diagnoses rheumatoid arthritis, but further testing is needed to determine the specific type., A patient with a long history of joint pain and stiffness is referred to a rheumatologist. After a thorough evaluation, including imaging and serological tests, the rheumatologist diagnoses unspecified rheumatoid arthritis., A patient experiences persistent joint pain, swelling, and reduced range of motion following a viral infection. The physician suspects rheumatoid arthritis but hasn't yet determined the specific type.

Documentation should include patient history, physical exam findings (joint swelling, tenderness, range of motion), imaging results, laboratory findings (rheumatoid factor, antibodies, inflammatory markers), and synovial fluid analysis (if performed).

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