ICD-10 Coding for Right Rotator Cuff Strain(S46.011A)
Complete ICD-10-CM coding and documentation guide for Right Rotator Cuff Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Rotator Cuff Strain
S46.0-S46.9Primary Range
Injury of muscle, fascia and tendon at shoulder and upper arm level
This range includes codes for traumatic injuries to the muscles and tendons of the shoulder, including strains.
Shoulder lesions
This range includes codes for non-traumatic shoulder conditions, such as tears and degenerative lesions.
Key Information: ICD-10 code for right rotator cuff strain
Essential facts and insights about Right Rotator Cuff Strain
Primary ICD-10-CM Code for right rotator cuff strain
Decision Criteria
clinical Criteria
- Presence of acute trauma leading to shoulder pain
documentation Criteria
- Specific mention of 'strain' and 'right shoulder'
Applicable To
- Acute traumatic strain of right rotator cuff
Excludes
- Non-traumatic rotator cuff tear (M75.121)
Clinical Validation Requirements
- Documented mechanism of injury (e.g., fall, lifting)
- Imaging showing strain without full-thickness tear
Code-Specific Risks
- Misclassification as non-traumatic tear
- Incorrect use for chronic conditions
Coding Notes
- Ensure documentation specifies trauma and laterality.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Sprain of rotator cuff capsule of right shoulder, initial encounter
S43.421ADifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic
M75.121Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Rotator Cuff Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S46.011A.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Increases risk of audit discrepancies., Financial: Potential for claim denials.
Mitigation Strategy
Ensure detailed documentation of the injury event.
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Misclassification can result in audit flags., Data Quality: Affects the accuracy of clinical data records.
Mitigation Strategy
Verify the mechanism of injury and document accordingly.
Impact
Failure to document trauma can lead to incorrect coding.
Mitigation Strategy
Ensure all documentation includes a clear description of the traumatic event.
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 Right Rotator Cuff Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Rotator Cuff Strain
Use these documentation templates to ensure complete and accurate documentation for Right Rotator Cuff Strain. These templates include all required elements for proper coding and billing.
Acute Right Rotator Cuff Strain
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Anatomic specificity
- Imaging results
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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