ICD-10 Coding for Biceps Tendinitis(M75.21, M75.22, M75.20)
Complete ICD-10-CM coding and documentation guide for Biceps Tendinitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Biceps Tendinitis
M75.2Primary Range
Bicipital tendinitis
This range includes codes specifically for biceps tendinitis, with laterality distinctions.
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 specified in the documentation. |
|
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 tendinitis
Essential facts and insights about Biceps Tendinitis
Primary ICD-10-CM Codes for biceps tendinitis
Decision Criteria
clinical Criteria
- Presence of tenderness in the bicipital groove and positive clinical tests
Applicable To
- Right shoulder biceps tendinitis
Excludes
- Other shoulder lesions
Clinical Validation Requirements
- Localized tenderness in the bicipital groove
- Positive Speed’s or Yergason’s test
- Imaging confirmation of tendon inflammation
Code-Specific Risks
- Risk of using unspecified code without laterality
Coding Notes
- Ensure laterality is documented to avoid unspecified code usage.
M75.22 - Bicipital tendinitis, left shoulder
Use when documentation specifies left shoulder involvement with clinical and imaging confirmation.
Applicable To
- Left shoulder biceps tendinitis
Excludes
- Other shoulder lesions
Clinical Validation Requirements
- Localized tenderness in the bicipital groove
- Positive Speed’s or Yergason’s test
- Imaging confirmation of tendon inflammation
Coding Notes
Ensure laterality is documented to avoid unspecified code usage.
M75.20 - Bicipital tendinitis, unspecified shoulder
Use only when laterality is not specified in the documentation.
Excludes
- Other shoulder lesions
Clinical Validation Requirements
- General shoulder pain without specified laterality
Coding Notes
Avoid using unspecified codes when laterality can be determined.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Rotator cuff tear or rupture
M75.1Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Adhesive capsulitis of shoulder
M75.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Biceps Tendinitis 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 incorrect treatment planning, Regulatory: Non-compliance with coding guidelines, Financial: Potential for denied claims
Mitigation Strategy
Always document laterality in clinical notes, Cross-check imaging reports for laterality
Impact
Reimbursement: May lead to reduced reimbursement rates, Compliance: Non-compliance with specificity requirements, Data Quality: Decreases accuracy of clinical data
Mitigation Strategy
Ensure documentation specifies laterality to use M75.21 or M75.22
Impact
Failure to document laterality can lead to audit flags.
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 Biceps Tendinitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Biceps Tendinitis
Use these documentation templates to ensure complete and accurate documentation for Biceps Tendinitis. These templates include all required elements for proper coding and billing.
Orthopedic evaluation for biceps tendinitis
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Diagnosis and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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