ICD-10 Coding for Right Shoulder Strain(S46.011A, M75.111)
Complete ICD-10-CM coding and documentation guide for Right Shoulder Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Shoulder Strain
S46.0-S46.9Primary Range
Injury of muscle and tendon at shoulder and upper arm level
This range includes codes for injuries to the muscles and tendons of the shoulder, including strains.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S46.011A | Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter | Use for initial encounter of acute right shoulder strain. |
|
| M75.111 | Unspecified rotator cuff tear/rupture of right shoulder, not specified as traumatic | Use for chronic or recurrent rotator cuff tears without acute trauma. |
|
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 shoulder strain
Essential facts and insights about Right Shoulder Strain
Primary ICD-10-CM Codes for right shoulder strain
Decision Criteria
clinical Criteria
- Presence of acute trauma and localized pain
coding Criteria
- Use for initial encounter of acute strain
Applicable To
- Acute strain of right rotator cuff
Excludes
- Chronic tear of rotator cuff (M75.111)
Clinical Validation Requirements
- Acute trauma such as lifting injury or fall
- Localized pain and tenderness
- Reduced range of motion
- Negative imaging for tear
Code-Specific Risks
- Incorrect use of 7th character for encounter type
Coding Notes
- Ensure laterality is documented. Use the correct 7th character for encounter type.
M75.111 - Unspecified rotator cuff tear/rupture of right shoulder, not specified as traumatic
Use for chronic or recurrent rotator cuff tears without acute trauma.
Applicable To
- Chronic tear of right rotator cuff
Excludes
- Acute strain of rotator cuff (S46.011A)
Clinical Validation Requirements
- Chronic symptoms over 3 months
- Recurrent weakness
- MRI-confirmed tear without acute trauma
Coding Notes
Ensure chronicity is documented. Differentiate from acute strains.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Encounter for orthopedic aftercare
Z47.89Differential 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 Shoulder 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 incorrect treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Use standardized templates, Review documentation for completeness
Impact
Reimbursement: May lead to denied claims or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of healthcare data.
Mitigation Strategy
Document laterality and specific injury details to use specific codes.
Impact
Reimbursement: Incorrect coding may affect reimbursement rates., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Affects data integrity and tracking of patient encounters.
Mitigation Strategy
Ensure correct 7th character is used based on encounter type.
Impact
Using unspecified codes can trigger audits due to lack of specificity.
Mitigation Strategy
Ensure detailed documentation and use specific codes.
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 Shoulder Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Shoulder Strain
Use these documentation templates to ensure complete and accurate documentation for Right Shoulder Strain. These templates include all required elements for proper coding and billing.
Acute right shoulder strain after lifting injury
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Pain location and severity
- Range of motion findings
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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