M35.3
BillablePolymyalgia rheumatica
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is M35.3 an HCC code?
Yes. M35.3 maps to Rheumatoid Arthritis and Inflammatory Connective Tissue Disease under the V24 model but is not retained in V28.
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for M35.3
For M35.3to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed M35.3 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
M35.3 is the ICD-10-CM diagnosis code for polymyalgia rheumatica. Polymyalgia rheumatica is an inflammatory condition causing severe muscle pain and stiffness, typically in the shoulders, hips, and neck, usually in older adults. M35.3 sits in the ICD-10-CM chapter for diseases of the musculoskeletal system and connective tissue (m00-m99), within the section covering systemic connective tissue disorders (m30-m36).
Under the older CMS-HCC V24 model, M35.3 maps to Rheumatoid Arthritis and Inflammatory Connective Tissue Disease (HCC 40) with a community, non-dual, aged base RAF weight of 0.307. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
This condition is often associated with temporal arteritis; check for concurrent diagnosis and code accordingly. Because M35.3 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for M35.3 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •This condition is often associated with temporal arteritis; check for concurrent diagnosis and code accordingly
- •Document elevated inflammatory markers (ESR/CRP) and response to corticosteroids to support the diagnosis
Clinical Significance
Polymyalgia rheumatica is a serious inflammatory condition in older adults requiring prompt corticosteroid therapy and careful monitoring for associated giant cell arteritis. The condition significantly impacts functional status and quality of life, with potential for serious vascular complications if untreated.
Documentation Requirements
- ✓Documentation of characteristic bilateral shoulder and hip girdle pain and stiffness
- ✓Age typically over 50 years at onset
- ✓Laboratory evidence of systemic inflammation (elevated ESR, CRP)
- ✓Response to corticosteroid therapy
- ✓Assessment for associated giant cell arteritis
- ✓Functional impact on activities of daily living
- ✓Exclusion of other inflammatory arthritides and malignancy
Excludes 1 — Do NOT code together
- polymyalgia rheumatica with giant cell arteritis (M31.5)
Commonly Confused Codes
- •M79.1 — Myalgia (non-specific muscle pain without inflammatory component)
- •M25.50 — Pain in unspecified joint (lacks specific PMR pattern)
- •M06.9 — Rheumatoid arthritis, unspecified (different inflammatory arthritis)
- •M77.9 — Enthesopathy, unspecified (localized rather than systemic)
- •R50.9 — Fever, unspecified (symptom only)