ICD-10 Coding for Rotator Cuff Tear Right Shoulder(M75.121, S46.011A)
Complete ICD-10-CM coding and documentation guide for Rotator Cuff Tear Right Shoulder. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Rotator Cuff Tear Right Shoulder
M75.1-M75.8Primary Range
Disorders of the rotator cuff
This range includes codes for various disorders of the rotator cuff, including tears and lesions.
Injury of muscle and tendon at shoulder and upper arm level
This range is used for traumatic injuries to the shoulder muscles and tendons.
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 the tear is non-traumatic and complete, confirmed by imaging. |
|
| S46.011A | Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter | Use when the tear is due to 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 rotator cuff tear right shoulder
Essential facts and insights about Rotator Cuff Tear Right Shoulder
Primary ICD-10-CM Codes for rotator cuff tear right shoulder
Decision Criteria
clinical Criteria
- MRI confirmation of full-thickness tear
documentation Criteria
- Documentation of non-traumatic etiology
Applicable To
- Degenerative rotator cuff tear
- Atraumatic rotator cuff tear
Excludes
- Traumatic rotator cuff tear (S46.011A)
Clinical Validation Requirements
- MRI showing full-thickness tear
- Clinical examination confirming weakness and limited range of motion
Code-Specific Risks
- Misclassification as traumatic
- Omission of laterality
Coding Notes
- Ensure documentation specifies the tear as non-traumatic and complete.
S46.011A - Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter
Use when the tear is due to a specific traumatic event.
Applicable To
- Acute traumatic rotator cuff tear
Excludes
- Non-traumatic rotator cuff tear (M75.121)
Clinical Validation Requirements
- History of trauma or injury
- Imaging showing acute tear
Coding Notes
Ensure documentation clearly states the traumatic nature of the tear.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Bursitis of right shoulder
M75.51Differential 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 Rotator Cuff Tear Right Shoulder to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.121.
Impact
Clinical: Leads to ambiguity in treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or delays.
Mitigation Strategy
Always specify 'right shoulder' in notes., Use templates that prompt for laterality.
Impact
Reimbursement: May result in incorrect DRG assignment and reimbursement., Compliance: Could lead to audits and compliance issues., Data Quality: Affects the accuracy of clinical data and reporting.
Mitigation Strategy
Verify the documentation for any mention of trauma or injury.
Impact
Failure to document trauma can lead to incorrect coding.
Mitigation Strategy
Implement thorough documentation practices for any traumatic events.
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 Rotator Cuff Tear Right Shoulder, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Rotator Cuff Tear Right Shoulder
Use these documentation templates to ensure complete and accurate documentation for Rotator Cuff Tear Right Shoulder. These templates include all required elements for proper coding and billing.
Chronic Degenerative Rotator Cuff Tear
Specialty: OrthopedicsRequired Elements
- Laterality
- Tear type and size
- Etiology (traumatic vs non-traumatic)
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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