Facebook tracking pixel

Shoulder Labral Tear - ICD-10 Documentation Guidelines

Dr. Claire Dave

A physician with over 10 years of clinical experience, she leads AI-driven care automation initiatives at S10.AI to streamline healthcare delivery.

TL;DR Unlock precise ICD-10 coding for shoulder labral tears. This clinician's guide details documentation for SLAP, Bankart, and degenerative tears, helping you avoid common errors and ensure accurate billing. Master your coding today.
Expert Verified

How Do You Accurately Document a Traumatic Shoulder Labral Tear in ICD-10?

When a patient presents with a traumatic shoulder labral tear, precise ICD-10 coding is crucial for accurate billing and continuity of care. The primary codes for a traumatic superior labral tear are found in the S43.43- category, which specifies a "Superior glenoid labrum lesion." To ensure proper documentation, your notes should clearly indicate the laterality of the injury—right shoulder (S43.431-), left shoulder (S43.432-), or unspecified (S43.439-). The seventh character of the code is equally important and signifies the encounter type: "A" for an initial encounter, "D" for a subsequent encounter, and "S" for sequela. For instance, a new patient with a right shoulder SLAP tear would be coded as S43.431A. Consider implementing a documentation checklist within your EMR to ensure these key details are never missed. This simple step can significantly reduce the risk of claim denials and audits.

 

What Are the Key Differences in Coding a SLAP Tear Versus a Bankart Lesion?

While both are types of labral tears, their location and mechanism of injury differ, which is reflected in their ICD-10 coding. A SLAP (Superior Labrum Anterior to Posterior) tear, as the name suggests, involves the superior aspect of the labrum. These are often coded with the S43.43- series of codes. In contrast, a Bankart lesion is a tear of the anteroinferior labrum, commonly associated with anterior shoulder dislocations. While there isn't a specific ICD-10 code for a Bankart lesion, it is often coded as a sprain of the shoulder joint, with the specific code depending on the associated injuries. For example, if the Bankart lesion is associated with a dislocation, you would code for the dislocation first, followed by a code for the labral tear. To simplify this, think of the glenoid as a clock face; SLAP tears typically occur between the 10 and 2 o'clock positions, while Bankart lesions are in the 2 to 6 o'clock region. Explore how using anatomical diagrams during patient consultations can not only improve patient understanding but also serve as a visual reminder for accurate coding.

 

How Should You Code a Degenerative Shoulder Labral Tear?

Unlike traumatic tears, degenerative labral tears are not coded with the "S" codes for injuries. Instead, you should use the M75.- series of codes for "Shoulder lesions." Specifically, M75.6- is used for a "Tear of labrum of degenerative shoulder joint." Similar to traumatic tears, laterality is key, with M75.61 for the right shoulder and M75.62 for the left. It's important to note that the 7th character extenders for encounter type (A, D, S) are not used with M-codes. The clinical history and imaging reports are your best friends in differentiating between a traumatic and a degenerative tear. Look for terms like "chronic," "wear and tear," or "degenerative changes" in the documentation to support the use of an M-code. Learn more about how AI-powered scribes can help you capture these crucial details from patient conversations, ensuring your coding is always on point.

 

What if the Labral Tear is Accompanied by a Rotator Cuff Tear?

It's not uncommon for a patient to present with both a labral tear and a rotator cuff tear. In such cases, you'll need to use multiple ICD-10 codes to fully capture the patient's condition. The primary diagnosis will depend on the main reason for the patient's visit. For example, if the primary reason for the encounter is the labral tear, you would list the appropriate S43.43- code first, followed by the code for the rotator cuff tear (e.g., S46.011A for a traumatic tear of the right rotator cuff, initial encounter). Conversely, if the rotator cuff tear is the more significant injury, you would list that code first. Clear documentation of the severity and acuity of each injury is essential for proper code sequencing. Consider implementing a standardized template for shoulder injury documentation in your practice to ensure all relevant details are captured consistently.

 

How Do You Properly Document a Posterior Labral Tear?

Posterior labral tears, while less common than their anterior counterparts, require specific documentation for accurate coding. While there isn't a single ICD-10 code that explicitly states "posterior labral tear," the most appropriate code is often M24.11-, which covers "Other articular cartilage disorders" of the shoulder. The description for this code includes "derangement of articular cartilage," which can encompass a posterior labral tear. As with other shoulder injuries, laterality is crucial, so be sure to specify right (M24.111) or left (M24.112) shoulder. Your clinical notes should clearly describe the location of the tear, supported by imaging findings, to justify the use of this code. To improve your documentation, consider using a shoulder diagram in your notes to mark the exact location of the tear.

 

What Are the Most Common ICD-10 Coding Mistakes to Avoid with Shoulder Labral Tears?

Even experienced clinicians can fall into common coding traps. One of the most frequent errors is using an unspecified code (e.g., S43.439A) when laterality is known. Always specify right or left whenever possible. Another pitfall is failing to use the correct 7th character extender for the encounter type (A, D, or S) with traumatic tears. This can lead to claim denials and payment delays. Finally, be mindful of the distinction between traumatic (S-codes) and degenerative (M-codes) tears. Using an injury code for a chronic, degenerative condition is a common mistake that can be avoided with careful review of the patient's history and imaging reports. To mitigate these risks, consider using a tool like S10.AI to proofread your clinical notes for clarity and completeness before finalizing them.

 

How Can You Use Timelines and Data Tables to Improve Your Documentation?

Consider incorporating a simple timeline or data table into your documentation for shoulder labral tears. This can help to clearly and concisely present the key information. For example:

 

Patient:                                                      [Patient Name]
Date of Injury: [Date]
Mechanism of Injury: [Description]
Laterality: [Right/Left]
Type of Tear: [SLAP/Bankart/Posterior/Degenerative]
Associated Injuries: [e.g., Rotator Cuff Tear]
ICD-10 Codes: [List of Codes]

 

This simple table can provide a quick and easy reference for anyone reviewing the patient's chart, and it can also help to ensure that you have captured all the necessary information for accurate coding. Explore how you can create custom templates in your EMR to automatically generate these tables for relevant patient encounters.

 
FAQs:
 
1) What clinical criteria are needed to support a diagnosis of shoulder labral tear for ICD-10 coding?

Accurate ICD-10 coding for shoulder labral tears starts with thorough, precise clinical documentation. Before assigning any codes, ensure your diagnosis is well-supported by key clinical findings.

Here’s what you should include:

Detailed History: Document mechanism of injury, duration of symptoms, and any previous shoulder issues.
Physical Exam Findings: Outline relevant tests—such as O'Brien's, Speed's, or crank tests—that indicate labral involvement.
Imaging Evidence: An MRI with findings confirming the type and location of labral tear (e.g., SLAP, Bankart, degenerative) is essential for both diagnosis and coding justification.
Symptoms and Functional Impact: Clearly describe pain quality, instability episodes, mechanical symptoms (like clicking or locking), and range of motion limitations.

Combining these elements not only satisfies clinical criteria but also supports compliant, defensible coding and billing.


2) What are the clinical validation requirements for coding a shoulder labral tear?

Accurate ICD-10 coding for shoulder labral tears isn’t just about picking the right code—it also hinges on clinical validation. To support your diagnosis and withstand payer scrutiny, your documentation should clearly establish the presence of a labral tear using a combination of imaging and clinical examination findings.

Key validation elements to include are:

Imaging Evidence: Clearly note MRI results demonstrating a labral lesion, such as a SLAP tear or Bankart lesion. Radiology should confirm the specific type of labral pathology.

Physical Exam Findings: Include positive results from established clinical tests. Common examples are:

O'Brien’s test (Active Compression Test): Frequently used for SLAP lesions.
Speed’s test: Supports SLAP pathology.

Other provocative maneuvers—such as the Anterior Slide Test or Crank Test—can also strengthen your documentation, especially if more than one test yields positive findings.

Correlation to Symptoms: Document how the imaging and clinical tests reflect the patient’s symptoms (e.g., pain, instability, mechanical clicking), further reinforcing the diagnosis.

By ensuring your charting addresses these criteria, you’ll create a robust record that supports the ICD-10 code you select and mitigates the risk of claim rejection or denial.


3) How should you distinguish between coding for debridement and repair of a labral tear?

One common documentation pitfall is confusing debridement with actual repair when coding labral tear procedures. This distinction has a direct impact on reimbursement, compliance, and the quality of your clinical data.

To clarify:

Debridement involves removing frayed or unstable labral tissue without restoring labral integrity. This should be coded as 29822 (Arthroscopic debridement, limited).
Repair, on the other hand, means anchoring and suturing the torn labrum back to the glenoid rim. In this scenario, use code 29807 (Arthroscopic repair of labral tear).

The easiest way to ensure coding accuracy is to document the specific technique used during the procedure. Did you perform suture anchor fixation (repair), or simply trim unstable tissue (debridement)? Noting these details in your operative note will reduce coding ambiguities and help prevent denials.
A quick tip: Review operative reports carefully, and if you’re ever uncertain whether the procedure was a debridement or a repair, consult with the operating surgeon or reference official CPT guidelines from the American Medical Association. Precision here pays dividends for accurate coding and claims processing.


4) What conditions are excluded from the shoulder labral tear ICD-10 codes?

When using ICD-10 codes for shoulder labral tears, it’s important to understand which diagnoses should be coded separately. Notably, rotator cuff tears—including those affecting the supraspinatus, infraspinatus, subscapularis, or teres minor—are classified differently and are not encompassed by the same ICD-10 codes used for labral injuries. Rotator cuff tears fall under the M75.1- series; be sure to distinguish between these two conditions in both your documentation and billing. Accurate separation helps avoid coding errors and ensures patients receive the most appropriate care pathways.


5) What differential diagnosis codes should be considered when coding for shoulder labral tears?

When documenting and coding for shoulder labral tears, it’s essential to distinguish them from other shoulder pathologies that may present with similar symptoms. Some of the most relevant differential diagnosis codes to consider include:

Rotator Cuff Tears (M75.1-): Unlike labral tears, these involve the tendons around the shoulder joint rather than the labrum itself. Careful review of imaging reports can help pinpoint whether you’re dealing with a tendon or labral issue.
Shoulder Impingement Syndrome (M75.4-): Pain and decreased range of motion may mimic labral injuries, so consider this diagnosis when clinical findings aren’t classic for a tear.
Biceps Tendon Lesions (M75.2-): SLAP tears in particular can resemble biceps tendon pathology, as they often involve the biceps anchor.
Glenohumeral Instability or Subluxation (M24.41-): Chronic instability can lead to labral and non-labral injuries—be clear whether instability is primary or secondary to the tear.
Frozen Shoulder/Adhesive Capsulitis (M75.0-): Stiffness and pain that do not localize to the labrum may warrant consideration of this diagnosis.

Compare clinical exam findings and correlate with imaging studies to ensure your diagnosis and coding reflect the true pathology. Being thorough with your differential diagnoses, and backing up your code selections with clear, detailed documentation, can help protect against denials and drive better clinical outcomes.
 

Practice Readiness Assessment

Is Your Practice Ready for Next-Gen AI Solutions?

Do you want to save hours in documentation?

Hey, we're s10.ai. We're determined to make healthcare professionals more efficient. Take our Practice Efficiency Assessment to see how much time your practice could save. Our only question is, will it be your practice?

S10
About s10.ai
AI-powered efficiency for healthcare practices

We help practices save hours every week with smart automation and medical reference tools.

+200 Specialists

Employees

4 Countries

Operating across the US, UK, Canada and Australia
Our Clients

We work with leading healthcare organizations and global enterprises.

• Primary Care Center of Clear Lake• Medical Office of Katy• Doctors Studio• Primary care associates
Real-World Results
30% revenue increase & 90% less burnout with AI Medical Scribes
75% faster documentation and 15% more revenue across practices
Providers earning +$5,311/month and saving $20K+ yearly in admin costs
100% accuracy in Nordic languages
Contact Us
Ready to transform your workflow? Book a personalized demo today.
Calculate Your ROI
See how much time and money you could save with our AI solutions.
Shoulder Labral Tear - ICD-10 Documentation Guidelines