As Gout Rises, Etiology and Coding Prove Important
The “disease of the kings” is making a comeback in the United States.
By Sheri Poe Bernard, CPC, CPC-H, CPC-P
It’s gout, and it’s called the “disease of kings” because attacks can be triggered by rich foods and liquor, historically available to royalty. A propensity toward gout also can be hereditary, and heirs to the crown would often be heirs to this malady, as well. Among the kingly gout sufferers are Charlemagne, Henry VIII, Charles IV, and Charles V. Notable democratic leaders have suffered the disease, as well, including John Hancock, Benjamin Franklin, Thomas Jefferson, and Martin Luther King, Jr.
The incidence of gout in the United States doubled in the last decade. It’s thought lifestyle issues precipitated this increase. Obesity, alcohol use, hypertension treated with diuretics, and a diet rich in meat and seafood increases a patient’s risk for gout, which is now considered the most common form of inflammatory arthritis in the United States. Aging population contributes to the incidence of gout, and genetics likely play a role in the increase, as well.
A Word About Gout
Gout occurs when uremic acid build-up in the blood leads to the deposit of monosodium uric crystals in the soft tissue of joints. Uric acid forms when purines break down in the blood. Meats, fish, shellfish, and beer are rich in purines. Nearly 75 percent of the cases of gout are first diagnosed in the big toe, and men outnumber female sufferers at least three-to-one. An acute attack may last a few days or weeks, and some patients may not have a repeat attack for years. Typically, gout has four stages:
- Asymptomatic accumulation of crystals in the tissue, with some tissue damage occurring;
- Acute flares with hot painful swelling. Uric acid levels may be within normal range;
- Intercritical segments in which the symptoms abate, but the damage continues to occur within the joint tissue; and
- Chronic gout, which is characterized by arthritis, soreness, joint aches, and in some cases, tophi (lumpy deposits of uric crystals in the soft tissue). The presence of tophi heralds the most severe form of the disease.
Criteria for diagnosing gout require uric crystals in synovial fluid, tophus pathology of uric crystals, or a preponderance of clinical and X-ray evidence. Diagnostic coding for gout changed last month with the addition of several new codes to ICD-9-CM. The codes allow for reporting of the acute or chronic nature of the gout.
Until the change, coders had only one code to report gouty arthritis (274.0 Gouty arthropathy). The new codes increase to five digits allowing for more specific reporting of the disease’s progression:
274.00 Gouty arthropathy, unspecified
274.01 Acute gouty arthropathy
274.02 Chronic gouty arthropathy without mention of tophus (tophi)
274.03 Chronic gouty arthropathy with tophus (tophi)
The hallmark of acute gouty arthropathy is searing pain. Many patients report they cannot tolerate even the weight of a sheet upon their afflicted joint, which is typically swollen, red, and hot. Podagra, the tell-tale painful inflammation of the big toe in acute gout attacks, has been reindexed for 2010 from 274.9 Gout, unspecified to 294.01 Acute gouty arthropathy. Chronic conditions also may be painful, but can be accompanied by arthritic deposits that produce disfigurement and impede joints.
Gout cannot occur without uremic acid buildup. However, this buildup, called hyperuricemia, may be resolved at the time of the diagnosis. In fact, only 50 percent of new cases of gout occur with hyperuricemia. Hyperuricemia is classified to 790.6 Other abnormal blood chemistry. Hyperuricemia can be a benign condition, but in some people can lead to the development of gout. Medications, including chemotherapy, immunosuppressants, aspirin, diuretics, and niacin can cause formation of gout crystals. Chronic conditions including kidney disease, multiple myeloma, hypothyroid, Kelley-Seegmiller or Lesch Nyhan syndrome, hemolytic anemia, and psoriasis may also predispose an individual to gout. If an underlying cause is documented, it should be coded in addition to the gout.
Gout can lead to the formation of kidney stones. If the stones are from uric acid, the correct code is 274.11 Uric acid nephrolithiasis rather than 592.0 Calculus of kidney.