Giant cell arteritis with polymyalgia rheumatica

This diagnosis code signifies a systemic inflammatory vasculitis affecting medium to large arteries, specifically giant cell arteritis (GCA), occurring concurrently with polymyalgia rheumatica (PMR). GCA typically presents with headache, jaw claudication, and visual disturbances, while PMR is characterized by pain and stiffness in the shoulders, neck, and hip girdles.

Apply this code when a patient has a confirmed diagnosis of giant cell arteritis and also exhibits the characteristic symptoms and diagnostic findings of polymyalgia rheumatica. Documentation should clearly state both conditions are present, often confirmed by biopsy for GCA and clinical criteria for PMR.

• Ensure documentation explicitly links GCA and PMR; if PMR is present without GCA, a different code is required.
• Consider sequencing this code as the primary diagnosis if it is the main reason for the encounter.
• Review for associated complications of GCA, such as vision loss or stroke, which would require additional codes.