ICD-10 Coding for Subacromial Bursitis(M75.41, M75.42)
Complete ICD-10-CM coding and documentation guide for Subacromial Bursitis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Subacromial Bursitis
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M75.41 | Bursitis of right shoulder | Use when bursitis is the primary diagnosis and affects the right shoulder. |
|
| M75.42 | Bursitis of left shoulder | Use when bursitis is the primary diagnosis and affects the left 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 subacromial bursitis
Essential facts and insights about Subacromial Bursitis
Primary ICD-10-CM Codes for subacromial bursitis
Decision Criteria
clinical Criteria
- Presence of subacromial pain and positive clinical tests
documentation Criteria
- Documentation must specify laterality and confirm diagnosis with imaging or clinical tests
Applicable To
- Subacromial bursitis of right shoulder
Excludes
- Rotator cuff syndrome (M75.1)
Clinical Validation Requirements
- Painful arc between 70–120° abduction
- Positive Hawkins-Kennedy test
- MRI showing bursal thickening
Code-Specific Risks
- Ensure laterality is specified to avoid unspecified code usage.
Coding Notes
- Ensure documentation specifies laterality and confirms bursitis through clinical tests or imaging.
M75.42 - Bursitis of left shoulder
Use when bursitis is the primary diagnosis and affects the left shoulder.
Applicable To
- Subacromial bursitis of left shoulder
Excludes
- Rotator cuff syndrome (M75.1)
Clinical Validation Requirements
- Painful arc between 70–120° abduction
- Positive Hawkins-Kennedy test
- MRI showing bursal thickening
Coding Notes
Ensure documentation specifies laterality and confirms bursitis through clinical tests or imaging.
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.
Adhesive capsulitis of shoulder
M75.0Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Subacromial Bursitis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.41.
Impact
Clinical: May lead to misdiagnosis, Regulatory: Increases audit risk, Financial: Potential for denied claims
Mitigation Strategy
Document all relevant clinical tests, Include imaging results in the patient record
Impact
Reimbursement: May lead to reduced reimbursement, Compliance: Increases risk of audit, Data Quality: Decreases specificity in clinical data
Mitigation Strategy
Specify laterality using M75.41 or M75.42
Impact
Using unspecified codes when laterality is known
Mitigation Strategy
Always document and code the specific shoulder affected
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 Subacromial Bursitis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Subacromial Bursitis
Use these documentation templates to ensure complete and accurate documentation for Subacromial Bursitis. These templates include all required elements for proper coding and billing.
Initial evaluation of shoulder pain
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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