ICD-10 Coding for Right Rotator Cuff Tear(M75.121, S46.011A)
Complete ICD-10-CM coding and documentation guide for Right 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 Right Rotator Cuff Tear
M75.1-M75.4Primary Range
Disorders of the rotator cuff
This range includes codes for both complete and partial tears of the rotator cuff, specifically for non-traumatic conditions.
Injury of muscle and tendon of the rotator cuff of shoulder
This range is used for traumatic injuries to the rotator cuff, indicating an acute event.
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 or rupture of right shoulder, not specified as traumatic | Use when there is a complete tear without a history of trauma. |
|
| S46.011A | Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter | Use for acute tears resulting 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 right rotator cuff tear
Essential facts and insights about Right Rotator Cuff Tear
Primary ICD-10-CM Codes for right rotator cuff tear
Decision Criteria
clinical Criteria
- MRI shows full-thickness tear
documentation Criteria
- No history of recent trauma
Applicable To
- Chronic rotator cuff tear
- Degenerative rotator cuff tear
Excludes
- Traumatic rotator cuff tear (S46.011A)
Clinical Validation Requirements
- MRI showing full-thickness tear
- Chronic shoulder pain without recent trauma
Code-Specific Risks
- Misclassification as traumatic without proper documentation
Coding Notes
- Ensure documentation specifies non-traumatic etiology.
S46.011A - Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter
Use for acute tears resulting from a specific traumatic event.
Applicable To
- Acute traumatic tear
Excludes
- Non-traumatic rotator cuff tear (M75.121)
Clinical Validation Requirements
- Documented traumatic event
- Acute onset of symptoms
Coding Notes
Ensure trauma is 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 Right 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 specify 'right' or 'left' in clinical notes., Use templates that prompt for laterality.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Verify the presence of a traumatic event in the patient's history.
Impact
Inadequate documentation of traumatic events leading to rotator cuff tears.
Mitigation Strategy
Implement thorough history-taking protocols to capture trauma details.
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 Tear, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Rotator Cuff Tear
Use these documentation templates to ensure complete and accurate documentation for Right Rotator Cuff Tear. These templates include all required elements for proper coding and billing.
Post-Operative Note for Rotator Cuff Repair
Specialty: Orthopedic SurgeryRequired Elements
- Patient's name and date of surgery
- Description of the tear and repair technique
- Post-operative instructions
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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