ICD-10 Coding for Full Thickness Rotator Cuff Tear(M75.121, S46.011A)
Complete ICD-10-CM coding and documentation guide for Full Thickness Rotator Cuff Tear. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Full Thickness Rotator Cuff Tear
M75.1-M75.12Primary Range
Rotator cuff tear or rupture, not specified as traumatic
This range covers non-traumatic rotator cuff tears, including full thickness tears.
Injury of muscle and tendon of the rotator cuff of shoulder
This range is used for traumatic rotator cuff tears.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M75.121 | Complete rotator cuff tear/rupture of right shoulder, not specified as traumatic | Use when there is a documented full-thickness tear of the right shoulder without trauma. |
|
| S46.011A | Traumatic rupture of right rotator cuff, initial encounter | Use when the tear is due to a traumatic event. |
|
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 full thickness rotator cuff tear
Essential facts and insights about Full Thickness Rotator Cuff Tear
Primary ICD-10-CM Codes for full thickness rotator cuff tear
Decision Criteria
clinical Criteria
- MRI shows full-thickness tear
documentation Criteria
- No trauma history documented
Applicable To
- Full thickness tear of right shoulder
Excludes
- Traumatic rotator cuff tear (S46.011)
Clinical Validation Requirements
- MRI confirmation of full-thickness tear
- Physical exam findings such as positive Drop-Arm Sign
Code-Specific Risks
- Misclassification if trauma is not properly documented
Coding Notes
- Ensure documentation specifies 'full-thickness' and laterality.
S46.011A - Traumatic rupture of right rotator cuff, initial encounter
Use when the tear is due to a traumatic event.
Applicable To
- Acute traumatic tear of right rotator cuff
Excludes
- Non-traumatic rotator cuff tear (M75.121)
Clinical Validation Requirements
- Documented traumatic event leading to tear
- Immediate onset of symptoms post-trauma
Coding Notes
Ensure trauma is documented as the cause of the tear.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Impingement syndrome of shoulder
M75.4Differential 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 Full Thickness Rotator Cuff Tear to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.121.
Impact
Clinical: Ambiguity in treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always document whether the tear is on the right or left shoulder.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Verify trauma history and use S46.011A if trauma is present.
Impact
Failure to document trauma can lead to incorrect coding.
Mitigation Strategy
Ensure trauma history is clearly documented when applicable.
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 Full Thickness Rotator Cuff Tear, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Full Thickness Rotator Cuff Tear
Use these documentation templates to ensure complete and accurate documentation for Full Thickness Rotator Cuff Tear. These templates include all required elements for proper coding and billing.
Chronic Degenerative Tear
Specialty: OrthopedicsRequired Elements
- Patient history
- Imaging results
- Physical exam findings
- No trauma history
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Full Thickness Rotator Cuff Tear? Ask your questions below.