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ICD-10 Coding for Biceps Tear(S46.11XA, M66.88)

Complete ICD-10-CM coding and documentation guide for Biceps Tear. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Biceps Tendon RuptureLong Head of Biceps Tear

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Related ICD-10 Code Ranges

Complete code families applicable to Biceps Tear

S46.1Primary Range

Injury of muscle and tendon of long head of biceps

This range covers traumatic injuries to the biceps tendon, including complete and partial tears.

M66.8

Spontaneous rupture of other tendons

This range is used for non-traumatic, degenerative tears of the biceps tendon.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
S46.11XAInjury of muscle and tendon of long head of biceps, right arm, initial encounterUse for acute traumatic tears of the right biceps tendon.
  • MRI confirmation of tear
  • Positive hook test
  • Sudden 'pop' sensation during activity
M66.88Spontaneous rupture of other tendons, other siteUse for non-traumatic, degenerative tears of the biceps tendon.
  • MRI showing degenerative changes
  • Absence of acute trauma history

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 biceps tear

Essential facts and insights about Biceps Tear

The ICD-10 code for a biceps tear depends on whether it is traumatic (S46.1) or non-traumatic (M66.8).

Primary ICD-10-CM Codes for biceps tear

S46.11XA
Injury of muscle and tendon of long head of biceps, right arm, initial encounter
Non-billable Code

Decision Criteria

clinical Criteria

  • Presence of acute trauma and MRI confirmation

documentation Criteria

  • Detailed mechanism of injury and clinical findings

Applicable To

  • Acute traumatic tear of right biceps tendon

Excludes

  • Non-traumatic tears (use M66.8)

Clinical Validation Requirements

  • MRI confirmation of tear
  • Positive hook test
  • Sudden 'pop' sensation during activity

Code-Specific Risks

  • Incorrect laterality
  • Missing associated injuries

Coding Notes

  • Ensure laterality is specified and confirm acute vs. chronic nature.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Superior glenoid labrum lesion, initial encounter

S43.42XA
Use when a concurrent SLAP lesion is identified.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Spontaneous rupture of other tendons, other site

M66.88
Use for non-traumatic, degenerative tears without acute injury.

Injury of muscle and tendon of long head of biceps, right arm, initial encounter

S46.11XA
Use for acute traumatic tears with a specific injury event.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Biceps Tear to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S46.11XA.

Impact

Clinical: Inaccurate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.

Mitigation Strategy

Always document the affected side in clinical notes.

Impact

Reimbursement: Claims may be denied or delayed., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.

Mitigation Strategy

Verify and document the affected side clearly in the medical record.

Impact

Reimbursement: Incorrect DRG assignment., Compliance: Violation of coding rules., Data Quality: Misleading clinical data.

Mitigation Strategy

Use M66.8 for degenerative or spontaneous tears.

Impact

Failure to specify laterality can lead to audit flags.

Mitigation Strategy

Ensure laterality is documented in all relevant sections of the medical record.

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 Biceps Tear, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Biceps Tear

Use these documentation templates to ensure complete and accurate documentation for Biceps Tear. These templates include all required elements for proper coding and billing.

Acute Traumatic Biceps Tear

Specialty: Orthopedics

Required Elements

  • Mechanism of injury
  • Clinical findings
  • Imaging results
  • Treatment plan

Example Documentation

Patient presents with acute right shoulder pain after lifting heavy object. Reports a 'pop' sound. MRI confirms complete rupture of the long head of the biceps tendon. Plan for surgical repair.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has biceps tear.
Good Documentation Example
45M sustained traumatic rupture of right long head biceps tendon during bench press, confirmed on MRI (3cm retraction). Positive hook test. Scheduled for open repair with tenodesis.
Explanation
The good example provides specific details about the mechanism, clinical findings, and planned treatment, which are necessary for accurate coding and billing.

Need help with ICD-10 coding for Biceps Tear? Ask your questions below.

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