ICD-10 Coding for Left Shoulder Rotator Cuff Tear(M75.122)
Complete ICD-10-CM coding and documentation guide for Left Shoulder 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 Shoulder Rotator Cuff Tear
M75.1-M75.12Primary Range
Rotator cuff tear or rupture, not specified as traumatic
This range includes codes for non-traumatic rotator cuff tears, specifying laterality and completeness.
Injury of muscle and tendon of the rotator cuff of shoulder
This range is used for traumatic tears of the rotator cuff, requiring documentation of an acute injury.
Key Information: ICD-10 code for left shoulder rotator cuff tear
Essential facts and insights about Left Shoulder Rotator Cuff Tear
Primary ICD-10-CM Code for left shoulder rotator cuff tear
Decision Criteria
clinical Criteria
- MRI confirms full-thickness tear without trauma history
documentation Criteria
- Laterality and completeness must be documented
Applicable To
- Complete tear of left rotator cuff
- Rupture of left rotator cuff
Excludes
- Traumatic tear of left rotator cuff (S46.012A)
Clinical Validation Requirements
- MRI or ultrasound confirmation of complete tear
- Documentation of no acute trauma history
- Physical exam findings of weakness and limited range of motion
Code-Specific Risks
- Confusion with traumatic tear codes
- Omission of laterality in documentation
Coding Notes
- Ensure documentation specifies 'complete' and 'non-traumatic' to avoid misclassification.
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.
Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter
S46.012ADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left Shoulder 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: Leads to potential misdiagnosis or treatment errors., Regulatory: Non-compliance with ICD-10 coding standards., Financial: Results in claim denials or reduced reimbursement.
Mitigation Strategy
Always document 'left' or 'right' in clinical notes.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Misclassification affects compliance with coding standards., Data Quality: Impacts accuracy of patient records and data analysis.
Mitigation Strategy
Verify trauma history and use M75.122 for non-traumatic cases.
Impact
High risk of audit if laterality is not documented.
Mitigation Strategy
Implement mandatory laterality checks in EHR systems.
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 Shoulder Rotator Cuff Tear, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Shoulder Rotator Cuff Tear
Use these documentation templates to ensure complete and accurate documentation for Left Shoulder Rotator Cuff Tear. These templates include all required elements for proper coding and billing.
Chronic Left Shoulder Pain with Rotator Cuff Tear
Specialty: OrthopedicsRequired Elements
- Patient history of shoulder pain
- Imaging results confirming tear
- Physical exam findings
- Surgical plan if applicable
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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