ICD-10 Coding for Bicep Tendonitis(M75.21, M75.22, M75.20)
Complete ICD-10-CM coding and documentation guide for Bicep Tendonitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bicep Tendonitis
M75.2Primary Range
Disorders of bursa and tendons in shoulder region
This range includes specific codes for bicipital tendinitis, focusing on the shoulder region.
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 right shoulder involvement with clinical and imaging confirmation. |
|
| M75.22 | Bicipital tendinitis, left shoulder | Use when documentation specifies left shoulder involvement with clinical and imaging confirmation. |
|
| M75.20 | Bicipital tendinitis, unspecified shoulder | Use only when laterality is not documented. |
|
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 tendonitis
Essential facts and insights about Bicep Tendonitis
Primary ICD-10-CM Codes for bicep tendonitis
Decision Criteria
clinical Criteria
- Presence of pain in bicipital groove with positive Speed’s test.
documentation Criteria
- Documentation must specify right shoulder and clinical findings.
Applicable To
- Right shoulder bicipital tendinitis
Clinical Validation Requirements
- Tenderness to palpation over bicipital groove, right shoulder
- Positive Speed’s test
- MRI shows fluid distension of biceps tendon sheath
Code-Specific Risks
- Risk of using unspecified codes when laterality is documented.
Coding Notes
- Ensure laterality is documented to avoid unspecified codes.
M75.22 - Bicipital tendinitis, left shoulder
Use when documentation specifies left shoulder involvement with clinical and imaging confirmation.
Applicable To
- Left shoulder bicipital tendinitis
Excludes
- Biceps tear (S46.2-)
- Spontaneous rupture of biceps (M66.8-)
Clinical Validation Requirements
- Tenderness to palpation over bicipital groove, left shoulder
- Positive Speed’s test
- MRI shows fluid distension of biceps tendon sheath
Coding Notes
Ensure laterality is documented to avoid unspecified codes.
M75.20 - Bicipital tendinitis, unspecified shoulder
Use only when laterality is not documented.
Excludes
- Biceps tear (S46.2-)
- Spontaneous rupture of biceps (M66.8-)
Clinical Validation Requirements
- General shoulder pain without specified laterality
Coding Notes
Avoid use if laterality is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Impingement syndrome
M75.4Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Rotator cuff tear or rupture
M75.1-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bicep Tendonitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.21.
Impact
Clinical: Inaccurate diagnosis and treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Always include laterality in clinical documentation, Use templates that prompt for laterality
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding specificity requirements., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Ensure documentation specifies laterality to use M75.21 or M75.22.
Impact
Use of unspecified codes when laterality is documented.
Mitigation Strategy
Ensure all clinical documentation specifies laterality.
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 Tendonitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bicep Tendonitis
Use these documentation templates to ensure complete and accurate documentation for Bicep Tendonitis. These templates include all required elements for proper coding and billing.
Orthopedic Progress Note (Post-Imaging)
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical exam findings
- Imaging results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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