Polymyalgia rheumatica

This code represents a chronic inflammatory condition characterized by widespread muscle pain and stiffness, primarily affecting the shoulders, neck, and hips. It is often associated with elevated inflammatory markers like ESR and CRP, and typically occurs in individuals over 50 years of age.

Apply this code when documentation confirms a diagnosis of polymyalgia rheumatica without any mention of giant cell arteritis. This diagnosis is typically supported by clinical presentation, physical examination findings, and laboratory results indicating inflammation.

• Do not code this when giant cell arteritis is also present; use M31.5 instead.
• Ensure the physician's documentation clearly distinguishes polymyalgia rheumatica from other inflammatory myopathies or arthropathies.
• Review the medical record for any associated conditions that may require additional coding.