ICD-10 M35.3
Billable / Specific HCC v28: 40Polymyalgia rheumatica
About ICD-10-CM M35.3
ICD-10-CM code M35.3 represents Polymyalgia rheumatica. This is a billable/specific code in the Musculoskeletal and Connective Tissue chapter (block M35). The 2026 edition of ICD-10-CM M35.3 became effective on October 1, 2025.
Coding Tips for M35.3
Specialist guidance from the PayerReady Medical Coding Team. Specificity warnings, HCC capture rules, sequencing notes.
M35.3 is a CMS-HCC v28 risk-adjustment code (category 40). To count for the patient Risk Adjustment Factor (RAF), document the diagnosis with MEAT language each calendar year: Monitored, Evaluated, Assessed, Treated. A diagnosis on the problem list alone does not satisfy CMS RADV audit standards. Include the diagnosis in the assessment with current status and current treatment plan.
Type 1 Excludes
Pure excludes, these codes can never be coded together with M35.3. The conditions are mutually exclusive (e.g., congenital vs acquired forms).
- polymyalgia rheumatica with giant cell arteritis (M31.5)
Medicare Advantage HCC Impact
Capture this diagnosis annually for accurate risk adjustment. Missed HCC captures are the #1 revenue leak in Medicare Advantage risk programs.
Medicare LCD Coverage for M35.3
Local Coverage Determinations (LCDs) from CMS MACs that list M35.3 as a covered diagnosis.
Showing top 10 of 433 total . Click a CPT for full coverage scope.
Commercial Payer Coverage
Coverage policies from major commercial payers referencing M35.3.
1 Cigna
5 Medicare
1 Aetna
CPT Codes Commonly Billed with M35.3
Procedures frequently paired with this diagnosis based on PayerReady's Dx↔Px linkage data.
We don't have CPT pairings indexed for this specific code yet. Use the CPT search above to find common procedures, or check your payer's published medical policy for code-specific guidance.
Convert M35.3 to ICD-9-CM
Per CMS General Equivalence Mappings (GEMs), useful for legacy data review and historical claim analysis.
| ICD-10 | ICD-9 | Mapping Flags |
|---|---|---|
| M35.3 | 725 | 00000 |
Flags format (5 digits): Approximate · No Map · Combination · Scenario · Choice List. Source: CMS 2017 GEMs (final version).
Codes Adjacent To M35.3
Other codes in section M30-M36 (Systemic connective tissue disorders).
ICD-10 M35.3, Billing FAQ
Is ICD-10 code M35.3 billable? +
Yes, M35.3 is a billable ICD-10-CM code that can appear as a primary or secondary diagnosis on claims.
What codes are Type 1 Excludes for M35.3? +
Type 1 Excludes (never code together with M35.3): polymyalgia rheumatica with giant cell arteritis (M31.5)
Does M35.3 affect Medicare Advantage HCC risk adjustment? +
Yes. M35.3 maps to CMS-HCC v28 category 40. Capture this diagnosis annually for accurate Medicare Advantage risk score.
What ICD-9 codes does M35.3 map to? +
Per CMS GEMs, M35.3 maps to ICD-9 codes: 725. Useful for legacy data review and historical claim analysis.
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Reviewed by the PayerReady Medical Coding Team
Verified against the CMS 2026 code set on June 1, 2026.
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