ICD-10 Coding for Left Rotator Cuff Tear(M75.122, S46.012A)
Complete ICD-10-CM coding and documentation guide for Left 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 Left Rotator Cuff Tear
M75.1-M75.12Primary Range
Non-traumatic rotator cuff tear or rupture of shoulder
This range covers non-traumatic tears of the rotator cuff, specifying complete or incomplete tears.
Injury of muscle and tendon of the rotator cuff of shoulder
This range is used for traumatic tears of the rotator cuff, indicating acute injuries.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M75.122 | Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic | Use when the tear is complete and non-traumatic, confirmed by imaging. |
|
| S46.012A | Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter | Use when the tear results from a specific 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 non-traumatic left rotator cuff tear
Essential facts and insights about Left Rotator Cuff Tear
Primary ICD-10-CM Codes for left rotator cuff tear
Decision Criteria
clinical Criteria
- MRI confirms full-thickness tear without trauma history.
Applicable To
- Full thickness tear
- Nontraumatic rupture
Excludes
- Traumatic rupture (S46.012A)
Clinical Validation Requirements
- MRI showing full-thickness tear
- Absence of trauma in patient history
Code-Specific Risks
- Incorrectly coding as traumatic when no trauma is documented.
Coding Notes
- Ensure documentation specifies 'non-traumatic' and 'complete'.
S46.012A - Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter
Use when the tear results from a specific traumatic event.
Applicable To
- Traumatic rupture
Excludes
- Non-traumatic rupture (M75.122)
Clinical Validation Requirements
- Documented trauma or injury
- Acute onset of symptoms
Coding Notes
Ensure trauma is clearly documented in the patient's history.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Left Rotator Cuff Tear to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.122.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Increases risk of audit issues., Financial: Can result in denied claims or reduced reimbursement.
Mitigation Strategy
Train staff to ask about and document any history of trauma., Use standardized templates that prompt for this information.
Impact
Reimbursement: Incorrect coding can lead to denied claims or incorrect DRG assignment., Compliance: Misclassification may result in compliance issues during audits., Data Quality: Affects the accuracy of clinical data and patient records.
Mitigation Strategy
Verify the patient's history for any documented trauma before coding.
Impact
Inadequate documentation of trauma can lead to incorrect coding.
Mitigation Strategy
Implement thorough documentation practices and regular staff training.
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 Left Rotator Cuff Tear, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Rotator Cuff Tear
Use these documentation templates to ensure complete and accurate documentation for Left Rotator Cuff Tear. These templates include all required elements for proper coding and billing.
Non-traumatic complete tear
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Imaging results
- Symptom onset and duration
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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