ICD-10 Coding for Right Shoulder Supraspinatus Tear Due to Trauma(S46.011A)
Complete ICD-10-CM coding and documentation guide for Right Shoulder Supraspinatus Tear Due to Trauma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Shoulder Supraspinatus Tear Due to Trauma
S46.0-S46.9Primary Range
Injury of muscle and tendon at shoulder and upper arm level
This range includes codes for traumatic injuries to the shoulder muscles and tendons, including the supraspinatus.
Shoulder lesions
This range is for non-traumatic shoulder lesions and should be avoided for traumatic cases.
Key Information: ICD-10 code for traumatic right shoulder supraspinatus tear
Essential facts and insights about Right Shoulder Supraspinatus Tear Due to Trauma
Primary ICD-10-CM Code for right shoulder supraspinatus tear due to trauma
Decision Criteria
clinical Criteria
- Presence of acute trauma and imaging confirmation
documentation Criteria
- Explicit mention of trauma in clinical notes
Applicable To
- Acute traumatic supraspinatus tear
Excludes
- Non-traumatic rotator cuff tear (M75.111)
Clinical Validation Requirements
- MRI or ultrasound confirming full-thickness tear
- Documented mechanism of trauma (e.g., fall, dislocation)
Code-Specific Risks
- Misclassification as non-traumatic if trauma is not documented
Coding Notes
- Ensure trauma is clearly documented to avoid incorrect coding as degenerative.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Shoulder Supraspinatus Tear Due to Trauma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S46.011A.
Impact
Clinical: Misclassification as non-traumatic., Regulatory: Potential audit issues., Financial: Incorrect reimbursement rates.
Mitigation Strategy
Always document the cause of injury.
Impact
Reimbursement: Incorrect DRG assignment leading to lower reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Ensure trauma is documented and use S46.011A.
Impact
Lack of trauma documentation can lead to incorrect coding.
Mitigation Strategy
Ensure detailed documentation of the injury mechanism.
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 Supraspinatus Tear Due to Trauma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Shoulder Supraspinatus Tear Due to Trauma
Use these documentation templates to ensure complete and accurate documentation for Right Shoulder Supraspinatus Tear Due to Trauma. These templates include all required elements for proper coding and billing.
Emergency Department Visit
Specialty: Emergency MedicineRequired Elements
- Mechanism of injury
- Immediate symptoms
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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