PROVIDER RESOURCE GUIDE Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) Definition This is a quick reference tool to help you with coding and documentation of quality measures that close care gaps. Percentage of patients age 18 or older who were diagnosed with rheumatoid arthritis, had two visits to discuss their RA, and were dispensed at least one ambulatory prescription for a disease- modifying anti-rheumatic drug (DMARD) during the measurement year. Codes DMARD HCPCS J0129, J0135, J0717, J1438, J1602, J1745, J3262, J3910-J3912, J7502, J7515-J7518, J9250, J9260, Q5102-5104, Q5109 Medications At least one prescription during the year for any of the following disease-modifying anti-rheumatic drugs. Drug category 5-Aminosalicylates Medications • Sulfasalazine Plans Affected • Commercial. • Medicaid. • Medicare Advantage. Alkylating agents • Cyclophosphamide Aminoquinolines • Hydroxychloroquine Quality Programs Affected • CMS Star Ratings. Anti-rheumatics • Auranofin Leflunomide • Methotrexate • Penicillamine Collection and Reporting Method • Administrative claim/encounter data and pharmacy data. Immunomodulators • Abatacept • Adalimumab • Anakinra • Certolizumab • Certolizumab pegol • Sarilumab • Etanercept • Golimumab • Infliximab • Rituximab • Tocilizumab Immunosuppressive agents Janus kinase (JAK) inhibitor • Azathioprine • Cyclosporine • Tofacitinib Baricitinab • • Mycophenolate Tetracyclines • Minocycline See HMSA Formularies at hmsa.com/help-center/your-hmsa-drug-formulary-list. HMSA will make the final decision about reimbursement when we receive a claim. Submitting a claim with a code from this document doesn’t guarantee payment. Payment of covered services depends on a patient’s plan benefits, your eligibility for payment, claim processing requirements, and your contract with HMSA. 8750-80122 2:19 go
Exclusions Standard Exclusions Timeframe Anytime during a patient’s history through the end of the measurement year. • HIV diagnosis • Patients in hospice • Pregnancy • Medicare patients age 66 and older as of December 31 of the measurement year who are living in a long-term care institution or enrolled in an Institutional SNP (I-SNP). Anytime during the measurement year. • Patients age 81 and older as of December 31of the measurement year with frailty. • Patients age 66 - 80 as of December 31 of the measurement year with advanced illness and frailty. best practice Tips and Best Practices to Help Close the Care Gap Proper coding for this measure is important because it helps prevent non-applicable patients from appearing in the measure. Miscoding issues commonly seen with this measure: • Coding for rheumatoid arthritis when it’s a “rule out work up.” • Coding for rheumatoid arthritis when a patient has another condition such as psoriatic arthritis or rheumatism. • If patient is in remission, consider coding History of RA in remission. For information about Medicare Star Ratings measures, please visit the Provider Resource Center at hmsa.com/portal/provider/zav_pel.aa.MED.100.htm. Information in this guide is based on National Committee for Quality Assurance (NCQA) HEDIS technical specifications. For details, visit ncqa.org. If you have any questions, call HMSA Provider Services at 948-6820 on Oahu or 1 (877) 304-4672 toll-free on the Neighbor Islands. HMSA will make the final decision about reimbursement when we receive a claim. Submitting a claim with a code from this document doesn’t guarantee payment. Payment of covered services depends on a patient’s plan benefits, your eligibility for payment, claim processing requirements, and your contract with HMSA.