Ending a Bureaucratic Nightmare
“We are happy to see this new code approved. The subject is of great interest for a disease that was recognized fairly recently,” says Dr. Edgerton. “Now that we have a way to document it, we expect to see improvements in care and in generating real-world evidence about it while making it easier for clinicians to speak the same language about it.”
The new code is also a step toward better defining and understanding the spectrum of spondyloarthritic diseases, which previously was defined largely by X-rays. “Now we’re getting more sophisticated at recognizing these subgroups, which have similar inflammatory arthritis of the spine. But much remains to be understood,” Dr. Edgerton says.
Dr. Stark estimates that 1.7 million people in the U.S. are living with nr-axSpA. The condition presents no X-ray evidence of structural damage to the sacroiliac joints, even though patients may have high symptom burden. A roughly equal number of people have the related condition, ankylosing spondylitis (AS), which is diagnosed with definitive X-ray evidence of structural change to the sacroiliac joints. An unknown number of patients will progress from a non-radiographic diagnosis to AS, and that can take years.
What sometimes happens, Dr. Stark adds, is that it can take five to eight years for a patient with back pain to reach a rheumatologist’s office and be given a diagnosis of nr-axSpA, which is often mistaken for other conditions. “These people can have an incredible journey to get to a diagnosis.” For the patient to finally reach the rheumatologist’s office and then be told that their condition cannot be documented because of coding limitations has been frustrating.
If the doctor prescribes treatment for a condition for which there is no code, the insurer’s verification process may not recognize it, thus triggering a claim denial, Dr. Edgerton says. The denied claim then has to go through an appeal process. “It’s a bureaucratic nightmare, all because there’s no code for this condition.”
The new code should help reduce the chance that an appropriate treatment prescribed for nr-axSpA would be denied by a payer. Now that the new code has a projected live date, EMR vendors will be updating their databases to include it. ACR members who have questions should reach out to the College for correct coding guidelines and ongoing updates, says Antanya Chung, ACR’s director of practice management. “As we get the code going, we’ll have more to add.” Ms. Chung can be reached at [email protected].
