ICD-10 Coding for Bicep Tendinopathy(M75.21, M75.22)
Complete ICD-10-CM coding and documentation guide for Bicep Tendinopathy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bicep Tendinopathy
M75.2-M75.22Primary Range
Disorders of bursa and tendons in shoulder region
This range includes specific codes for bicipital tendinitis with laterality.
Synovitis and tenosynovitis
Used when tendon involvement is unspecified or not specific to the biceps.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M75.21 | Bicipital tendinitis, right shoulder | Use when documentation specifies biceps tendon involvement in the right shoulder. |
|
| M75.22 | Bicipital tendinitis, left shoulder | Use when documentation specifies biceps tendon involvement in the left shoulder. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for bicep tendinopathy
Essential facts and insights about Bicep Tendinopathy
Primary ICD-10-CM Codes for bicep tendinopathy
Decision Criteria
clinical Criteria
- Presence of bicipital groove tenderness and positive Speed’s test
documentation Criteria
- Specific mention of biceps tendon involvement and laterality
Applicable To
- Long head of biceps tendinitis
Excludes
- Rotator cuff tear (M75.12-)
Clinical Validation Requirements
- Pain localized to bicipital groove
- Positive Speed’s and Yergason’s tests
- Ultrasound showing tendon sheath fluid ≥3mm
Code-Specific Risks
- Confusion with general shoulder tendinitis codes
- Missing laterality documentation
Coding Notes
- Ensure documentation specifies the biceps tendon and laterality.
M75.22 - Bicipital tendinitis, left shoulder
Use when documentation specifies biceps tendon involvement in the left shoulder.
Applicable To
- Long head of biceps tendinitis
Excludes
- Rotator cuff tear (M75.12-)
Clinical Validation Requirements
- Pain localized to bicipital groove
- Positive Speed’s and Yergason’s tests
- Ultrasound showing tendon sheath fluid ≥3mm
Coding Notes
Ensure documentation specifies the biceps tendon and laterality.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Incomplete rotator cuff tear or rupture of shoulder, not specified as traumatic
M75.12-Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bicep Tendinopathy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.21.
Impact
Clinical: May lead to inappropriate treatment side., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Always include laterality in documentation., Use templates that prompt for laterality.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 specificity requirements., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Use M75.21 or M75.22 when biceps involvement is documented.
Impact
High risk of audit if laterality is not documented for shoulder conditions.
Mitigation Strategy
Implement mandatory laterality fields in EHR templates.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Bicep Tendinopathy, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bicep Tendinopathy
Use these documentation templates to ensure complete and accurate documentation for Bicep Tendinopathy. These templates include all required elements for proper coding and billing.
Orthopedic Evaluation
Specialty: OrthopedicsRequired Elements
- Location of pain
- Mechanism of injury
- Imaging results
- Physical exam findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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