ICD-10 Coding for Rotator Cuff Tear(S46.011A, M75.121)
Complete ICD-10-CM coding and documentation guide for 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 Rotator Cuff Tear
S46.01-S46.02Primary Range
Injury of muscle(s) and tendon(s) of the rotator cuff of shoulder
This range covers traumatic tears of the rotator cuff, specifying laterality and encounter type.
Rotator cuff tear or rupture, not specified as traumatic
This range is used for non-traumatic or degenerative tears of the rotator cuff.
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 acute traumatic tears of the right shoulder with initial encounter. |
|
| M75.121 | Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic | Use for chronic degenerative tears of the right shoulder. |
|
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
Essential facts and insights about Rotator Cuff Tear
Primary ICD-10-CM Codes for rotator cuff tear
Decision Criteria
clinical Criteria
- Documented traumatic event leading to tear
Applicable To
- Acute traumatic full-thickness tear of right shoulder
Excludes
- Non-traumatic rotator cuff tear (M75.1-)
Clinical Validation Requirements
- Mechanism of injury documented
- MRI confirming full-thickness tear
Code-Specific Risks
- Misclassification as chronic due to duration
Coding Notes
- Ensure documentation specifies the traumatic nature and laterality.
M75.121 - Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic
Use for chronic degenerative tears of the right shoulder.
Applicable To
- Chronic degenerative full-thickness tear of right shoulder
Excludes
- Traumatic rotator cuff tear (S46.01-)
Clinical Validation Requirements
- No trauma history
- MRI showing degenerative changes
Coding Notes
Ensure documentation specifies degenerative nature and laterality.
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 Rotator Cuff Tear to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S46.011A.
Impact
Clinical: Loss of detailed clinical information., Regulatory: Potential audit flags for lack of specificity., Financial: Reduced reimbursement due to non-specific coding.
Mitigation Strategy
Ensure complete documentation before coding, Query providers for missing details
Impact
Reimbursement: Incorrect DRG assignment affecting payment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Classify based on cause (traumatic vs. degenerative), not duration.
Impact
Risk of audits due to use of unspecified codes.
Mitigation Strategy
Ensure documentation supports specific code selection.
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, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Rotator Cuff Tear
Use these documentation templates to ensure complete and accurate documentation for Rotator Cuff Tear. These templates include all required elements for proper coding and billing.
Acute Traumatic Rotator Cuff Tear
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Imaging results
- Clinical tests
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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