Understanding Acromioclavicular Joint Separation (AC Joint Separation, Shoulder Separation)? This guide provides information on diagnosis, clinical documentation, and medical coding for AC Joint Separation injuries. Learn about healthcare best practices for documenting and coding this shoulder condition for accurate medical records and billing. Find resources for medical professionals dealing with Acromioclavicular Joint injuries.
Also known as
Dislocation of acromioclavicular joint
Covers separation of the acromioclavicular (AC) joint.
Dislocation of shoulder and upper arm
Includes various shoulder dislocations, including AC joint.
Injuries to shoulder and upper arm
Encompasses a broader range of shoulder injuries.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the AC joint separation traumatic?
Yes
Type of AC separation specified?
No
Is it atraumatic/non-traumatic?
When to use each related code
| Description |
|---|
| Shoulder separation, AC joint disrupted. |
| Shoulder dislocation, humerus out of socket. |
| Shoulder sprain, ligaments stretched or torn. |
Missing or incorrect laterality (right, left, bilateral) can lead to claim denials or inaccurate reimbursement.
Documenting the grade of AC separation (I-VI) is crucial for accurate coding and reflects severity for proper payment.
Distinguishing between traumatic and atraumatic causes impacts code selection and appropriate clinical documentation improvement efforts.
Q: How can I differentiate between a Type I, II, and III acromioclavicular joint separation using physical examination and imaging findings in a clinical setting?
A: Differentiating between AC joint separation types relies on a combination of physical exam findings and imaging. Type I injuries present with mild tenderness and no visible deformity. Palpation may reveal slight AC joint widening. Radiographs are typically normal or show minimal changes. Type II injuries involve a complete tear of the acromioclavicular ligament, but intact coracoclavicular ligaments. Patients exhibit moderate pain, a visible step-off deformity at the AC joint, and positive horizontal adduction stress test. Radiographs may show slight superior displacement of the clavicle. Type III injuries involve complete tears of both the acromioclavicular and coracoclavicular ligaments. This results in significant pain, a prominent step-off deformity, and superior clavicle displacement on palpation and radiographs. Explore how the Rockwood classification further delineates severe AC joint separations (Types IV-VI) involving significant displacement and soft tissue injury. Consider implementing standardized imaging protocols for accurate assessment and classification.
Q: What are the best evidence-based conservative management strategies for a Type II acromioclavicular joint separation, including initial immobilization recommendations and rehabilitation exercises?
A: Conservative management of Type II AC joint separations generally includes initial immobilization with a sling for pain control and to protect the joint. The duration of immobilization varies, typically ranging from a few days to a few weeks, depending on the patient's symptoms and activity level. Early range of motion exercises are crucial to prevent stiffness, followed by a progressive strengthening program focusing on the rotator cuff and scapular stabilizers. Pain management modalities such as ice, heat, and NSAIDs can be beneficial. Learn more about the current research comparing early mobilization versus prolonged immobilization in Type II AC joint separations for optimal functional recovery. Consider implementing patient-specific exercise programs based on their pain tolerance and progress.
Patient presents with complaints consistent with acromioclavicular joint separation, also known as AC joint separation or shoulder separation. Onset of symptoms occurred on [Date of Onset] following a [Mechanism of Injury - e.g., fall on an outstretched arm, direct blow to the shoulder]. Patient reports [Character of pain - e.g., sharp, aching] pain localized to the acromioclavicular joint region, exacerbated by [Exacerbating factors - e.g., arm movement, palpation]. Physical examination reveals [Positive physical exam findings - e.g., tenderness over the AC joint, visible step-off deformity, positive cross-arm adduction test]. Range of motion is limited due to pain in [Specific movements affected - e.g., abduction, flexion]. Neurovascular status is intact distally. Differential diagnosis includes clavicle fracture, rotator cuff tear, and shoulder dislocation. Radiographic imaging, including [Specific imaging ordered - e.g., AP, axillary, and Zanca views of the shoulder], was performed to confirm the diagnosis and assess the degree of ligamentous injury, consistent with a Rockwood classification of [Rockwood classification - e.g., Type I, Type II, Type III]. Current treatment plan includes [Initial treatment plan - e.g., RICE protocol (rest, ice, compression, elevation), analgesics, referral to physical therapy]. Patient education provided regarding activity modification and follow-up care. Prognosis is [Prognosis - e.g., good with conservative management, possible need for surgical intervention depending on severity]. Follow-up appointment scheduled for [Date of follow-up] to assess response to treatment and determine the need for further intervention, including potential surgical options such as acromioclavicular joint reconstruction if indicated. ICD-10 code [ICD-10 code - e.g., S43.511A] is being considered for this encounter.