ICD-10 Coding for Tear of Rotator Cuff(M75.11, S46.011A)
Complete ICD-10-CM coding and documentation guide for Tear of Rotator Cuff. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Tear of Rotator Cuff
M75.1-M75.2Primary Range
Non-traumatic rotator cuff tear
Covers degenerative tears without acute injury history.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M75.11 | Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic | Use when imaging confirms partial tear without trauma history. |
|
| S46.011A | Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter | Use when there is a documented traumatic event leading to the tear. |
|
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: How do you code a rotator cuff tear?
Essential facts and insights about Tear of Rotator Cuff
Primary ICD-10-CM Codes for tear of rotator cuff
Decision Criteria
clinical Criteria
- Partial tear confirmed by imaging
documentation Criteria
- Absence of trauma history
Applicable To
- Partial tear of rotator cuff
Excludes
- Complete tear of rotator cuff (M75.12)
Clinical Validation Requirements
- MRI showing partial-thickness tear
- Physical exam with positive impingement signs
Code-Specific Risks
- Misclassification as complete tear
- Omission of laterality
Coding Notes
- Ensure laterality is documented.
S46.011A - Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter
Use when there is a documented traumatic event leading to the tear.
Applicable To
- Traumatic tear of rotator cuff
Excludes
- Non-traumatic tear of rotator cuff (M75.1-)
Clinical Validation Requirements
- Documented mechanism of injury
- Acute onset of symptoms
Coding Notes
Ensure the traumatic event is clearly documented.
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 Tear of Rotator Cuff to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.11.
Impact
Clinical: Leads to incomplete diagnosis, Regulatory: Non-compliance with coding standards, Financial: Potential claim denials
Mitigation Strategy
Always specify right or left in notes, Double-check imaging reports for laterality
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Misclassification may result in compliance issues., Data Quality: Affects the accuracy of clinical data.
Mitigation Strategy
Verify the presence or absence of a traumatic event in documentation.
Impact
Lack of clear documentation of traumatic events can lead to audit issues.
Mitigation Strategy
Ensure all traumatic events are clearly documented in patient history.
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 Tear of Rotator Cuff, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Tear of Rotator Cuff
Use these documentation templates to ensure complete and accurate documentation for Tear of Rotator Cuff. These templates include all required elements for proper coding and billing.
Orthopedic evaluation for suspected rotator cuff tear
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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