Summary & Overview
CPT 3471F: Rheumatoid Arthritis Moderate Disease Activity Score
CPT code 3471F represents documentation that a patient with rheumatoid arthritis has a moderate disease activity score based on a standardized assessment. This measure is clinically important because it quantifies inflammation and pain, and it commonly informs therapeutic decisions such as medication adjustment. Nationally, structured disease activity scoring supports quality measurement, care coordination, and appropriate use of disease-modifying therapies for RA.
Key payers covered in this analysis include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find an overview of the clinical context for 3471F, typical sites of service and service type, and what the code signifies for documentation and quality reporting. The publication also outlines common benchmarks and policy-relevant considerations for payers and provider organizations, and summarizes related clinical implications for treatment monitoring. Data not available in the input is noted where applicable.
Billing Code Overview
CPT code 3471F documents a moderate rheumatoid arthritis (RA) disease activity score. The code indicates that the clinician has assessed the patient’s RA activity level using a standardized disease activity scoring method and determined the result falls within the moderate range. The score helps quantify the degree of inflammation and the patient’s level of pain due to rheumatoid arthritis and may inform medication adjustments.
Service type: Disease activity assessment and clinical evaluation for rheumatoid arthritis
Typical site of service: Outpatient clinic or ambulatory rheumatology practice
Clinical & Coding Specifications
Clinical Context
A 58-year-old female with established seropositive rheumatoid arthritis presents to a rheumatology clinic for routine disease activity assessment. She reports increased morning stiffness and persistent joint pain despite stable dosing of a disease-modifying antirheumatic drug (DMARD). The clinic nurse collects joint counts and the provider documents patient global assessment and laboratory inflammatory markers as needed. The provider calculates the Rheumatoid Arthritis Disease Activity Score (DAS28) during the visit and determines the patient has a moderate disease activity level. Based on the DAS28 result, the provider documents the score, discusses activity level with the patient, and considers therapeutic adjustment during the same visit. Typical site of service is an outpatient rheumatology clinic; the service type is disease activity assessment and documentation of clinical decision-making related to RA management.
Coding Specifications
| Modifier | Description | When to Use |
|---|---|---|
25 | Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service | Use when an E/M visit is performed and documented separately in addition to the disease activity assessment when both meet requirements. |
59 |