How To Use CPT Code 3471F

CPT 3471F describes the disease activity level of a patient with rheumatoid arthritis (RA) and is used to assess the degree of inflammation and the level of pain experienced by the patient. This article will provide an overview of CPT code 3471F, including its official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, and examples.

1. What is CPT Code 3471F?

CPT 3471F is a code used to determine the disease activity level of a patient with rheumatoid arthritis (RA). It helps assess the extent of inflammation and the patient’s level of pain due to the disease. The provider may adjust the patient’s rheumatoid arthritis medication based on the results of this score. This code is specifically used when the patient has a moderate disease activity score for RA.

2. Official Description

The official description of CPT code 3471F is: ‘Rheumatoid arthritis (RA) disease activity, moderate (RA).’ This code is used to indicate the moderate disease activity level of a patient with rheumatoid arthritis.

3. Procedure

1. The provider evaluates the patient’s rheumatoid arthritis disease activity, considering factors such as the number of swollen or tender joints, erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) levels in the blood to measure inflammation, and the Visual Analogue Score (VAS) to assess the level of pain.

4. Qualifying circumstances

CPT code 3471F is used for patients with rheumatoid arthritis who have a moderate disease activity level. Rheumatoid arthritis is an autoimmune disorder that causes inflammation, pain, and loss of joint function. The disease activity score helps determine the severity of the disease and guides treatment decisions. The provider must document the disease activity score and the date of the test in the patient’s medical record.

5. When to use CPT code 3471F

CPT code 3471F should be used when a patient with rheumatoid arthritis has a moderate disease activity level. It is important to accurately assess the disease activity level to guide treatment decisions and adjust medication as necessary. This code should not be used for patients with mild or severe disease activity levels.

6. Documentation requirements

To support a claim for CPT code 3471F, the provider must document the following information:

• Patient’s diagnosis of rheumatoid arthritis
• Disease activity score indicating a moderate disease activity level
• Date of the test

7. Billing guidelines

When billing for CPT code 3471F, ensure that the patient has a documented moderate disease activity level for rheumatoid arthritis. This code should not be reported with other codes related to disease activity levels for rheumatoid arthritis. It is important to accurately report the disease activity level to ensure appropriate reimbursement.

8. Historical information

CPT code 3471F was added to the Current Procedural Terminology system on January 1, 2010. There have been no updates to the code since its addition.

9. Examples

1. A patient with rheumatoid arthritis has a disease activity score indicating a moderate disease activity level. The provider adjusts the patient’s medication based on the results of the score.
2. A rheumatologist evaluates a patient with rheumatoid arthritis and determines that the disease activity level is moderate. The provider documents the score in the patient’s medical record for future reference.
3. A patient with rheumatoid arthritis undergoes a disease activity assessment, and the results indicate a moderate disease activity level. The provider discusses treatment options with the patient based on the score.
4. A rheumatology nurse assesses the disease activity level of a patient with rheumatoid arthritis and finds it to be moderate. The nurse communicates the results to the provider for further evaluation and treatment planning.
5. A patient with rheumatoid arthritis undergoes regular disease activity assessments, and the most recent score indicates a moderate disease activity level. The provider discusses potential treatment adjustments with the patient.
6. A rheumatologist evaluates a patient with rheumatoid arthritis and determines that the disease activity level is moderate. The provider discusses lifestyle modifications and medication options to manage the disease based on the score.
7. A patient with rheumatoid arthritis has a disease activity score indicating a moderate disease activity level. The provider recommends physical therapy and other non-pharmacological interventions to help manage the disease.
8. A rheumatology nurse assesses the disease activity level of a patient with rheumatoid arthritis and finds it to be moderate. The nurse provides education to the patient on self-management strategies and the importance of medication adherence.
9. A patient with rheumatoid arthritis undergoes regular disease activity assessments, and the most recent score indicates a moderate disease activity level. The provider discusses the potential benefits and risks of different treatment options with the patient.
10. A rheumatologist evaluates a patient with rheumatoid arthritis and determines that the disease activity level is moderate. The provider recommends lifestyle modifications, such as exercise and stress management, to help improve the patient’s overall well-being.