Chronic left shoulder pain diagnosis, including persistent and long-term left shoulder pain, requires accurate clinical documentation for medical coding and billing. This resource helps healthcare professionals understand the causes, symptoms, and treatment options for chronic left shoulder pain to ensure proper diagnosis coding and improve patient care. Learn about relevant ICD-10 codes, differential diagnosis considerations, and best practices for documenting left shoulder pain in medical records.
Also known as
Pain in left shoulder
Covers chronic and other types of left shoulder pain.
Rotator cuff syndrome or tear, left shoulder
Shoulder pain from rotator cuff issues, a common cause of chronic pain.
Pain in left upper limb
Includes more general upper limb pain if shoulder-specific codes dont fit.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the left shoulder pain traumatic in origin?
Yes
Is there a current injury?
No
Is there a specific underlying condition (e.g., arthritis, rotator cuff tear)?
When to use each related code
| Description |
|---|
| Chronic left shoulder pain lasting > 3 months. |
| Left shoulder adhesive capsulitis (frozen shoulder). |
| Left rotator cuff tear. |
Coding requires clear left shoulder laterality documentation. Missing or unclear laterality can lead to incorrect coding and claims rejection.
Insufficient documentation of chronicity (duration of pain) may lead to downcoding to an acute pain diagnosis, impacting reimbursement.
Chronic pain often has an underlying cause (e.g., rotator cuff tear). Failure to code the underlying etiology with the chronic pain diagnosis can lead to underpayment and compliance issues.
Q: What are the most common differential diagnoses for chronic left shoulder pain in patients presenting with persistent symptoms for over 3 months?
A: Chronic left shoulder pain lasting over 3 months can present a diagnostic challenge. Common differential diagnoses include rotator cuff tendinopathy or tear, adhesive capsulitis (frozen shoulder), osteoarthritis, referred pain from the cervical spine, or less commonly, thoracic outlet syndrome, peripheral nerve entrapment, or complex regional pain syndrome. A thorough clinical evaluation including a detailed history, physical exam assessing range of motion, strength, and neurological function, and appropriate imaging studies such as X-rays, MRI, or ultrasound are crucial to differentiate these conditions and guide treatment. Explore how a multidisciplinary approach can improve outcomes in complex cases.
Q: How can I effectively differentiate between rotator cuff tendinopathy and a rotator cuff tear in a patient with chronic left shoulder pain using physical examination and imaging techniques?
A: Differentiating rotator cuff tendinopathy from a tear requires a combination of physical exam maneuvers and imaging. On exam, tendinopathy may present with painful arc of motion, weakness with resisted external rotation or abduction, and positive impingement tests. A tear may exhibit significant weakness, positive drop arm test, and limited active range of motion. Imaging, particularly MRI or ultrasound, can confirm the diagnosis, with MRI providing better visualization of the tear's size and location, and ultrasound potentially demonstrating dynamic impingement. Consider implementing a standardized assessment protocol for shoulder pain to ensure consistent evaluation. Learn more about the specific imaging criteria for diagnosing different grades of rotator cuff tears.
Patient presents with chronic left shoulder pain, a persistent and long-term discomfort localized to the left shoulder region. Onset of pain is reported as [Onset - e.g., gradual, sudden, insidious], with a duration of [Duration - e.g., several months, years]. The patient describes the pain as [Pain quality - e.g., aching, sharp, burning, throbbing] and rates its severity as [Severity on a scale of 0-10]. Pain is [Exacerbating/relieving factors - e.g., exacerbated by overhead activities, relieved by rest]. Associated symptoms may include [Associated symptoms - e.g., stiffness, limited range of motion, weakness, numbness, tingling in the arm or hand]. Physical examination reveals [Objective findings - e.g., tenderness to palpation at the [Specific location - e.g., acromioclavicular joint, bicipital tendon], reduced active and passive range of motion, positive [Specific tests - e.g., Neer impingement test, Hawkins-Kennedy test]]. Differential diagnoses include rotator cuff tear, adhesive capsulitis (frozen shoulder), osteoarthritis, impingement syndrome, and cervical radiculopathy. Initial treatment plan includes [Treatment plan - e.g., conservative management with NSAIDs, physical therapy referral for range of motion and strengthening exercises, ice/heat therapy]. Further investigation with [Diagnostic tests - e.g., X-ray, MRI, ultrasound] may be warranted to evaluate for underlying pathology. Patient education provided on proper body mechanics, activity modification, and pain management strategies. Follow-up scheduled in [Duration - e.g., 2 weeks] to assess response to treatment and adjust plan as needed. ICD-10 code: [Appropriate ICD-10 code - e.g., M75.82, M25.512, depending on specific diagnosis] should be considered.