Summary & Overview
CPT 3475F: Rheumatoid Arthritis Prognosis Assessment, Poor Prognosis
CPT code 3475F documents a clinician’s assessment that a patient with rheumatoid arthritis has a poor disease prognosis, reflecting expectations of persistent or progressive disease activity. Nationally, clear documentation of prognosis influences clinical decision-making, disease management plans, and payer determinations tied to disease severity. This code is used in rheumatology practice settings to signal higher-risk patients who may need intensified monitoring or therapeutic strategies.
Key payers covered in this overview include Aetna, Blue Cross Blue Shield, Cigna Health, UnitedHealthcare, and Medicare. Readers will find a concise explanation of the code’s clinical meaning and service context, plus an outline of typical sites of service. The publication also provides benchmarks and coding practice guidance, discusses relevant policy updates affecting documentation and coverage, and places the code in clinical context for rheumatology care pathways. Data not available in the input will be noted where applicable.
Billing Code Overview
CPT code 3475F indicates that the provider has assessed the disease prognosis — the expected future progression — for a patient with rheumatoid arthritis and determined the patient has a poor prognosis. This code documents the provider's evaluation of disease severity and the likelihood of persistent or progressive disease activity.
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Service type: Clinical assessment of disease prognosis for rheumatoid arthritis
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Typical site of service: Rheumatology clinic or outpatient specialty clinic
Clinical & Coding Specifications
Clinical Context
A 58-year-old female with seropositive rheumatoid arthritis (RA) of 10 years duration presents to a rheumatology clinic for longitudinal disease management. Despite treatment with methotrexate and a TNF inhibitor, she has persistent swollen joints, elevated inflammatory markers (CRP and ESR), progressive radiographic erosions in the hands, and declining physical function. The provider performs a comprehensive assessment of disease prognosis to determine severity and likelihood of continued disease activity and joint damage.
The clinical workflow includes: a focused history (disease duration, prior DMARDs and biologics, extra-articular features, comorbidities, smoking status), review of objective measures (joint counts, CRP/ESR, imaging reports), assessment of functional status and patient-reported outcomes, synthesis of prognostic indicators (seropositivity, high acute phase reactants, early erosions, inadequate therapeutic response), documentation of a determination of poor prognosis, and coding 3475F when the patient is assessed as having a poor prognosis to support care planning and potential escalation of therapy.
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 | Use when a distinct E/M service is provided on the same day as a procedure or assessment visit |