Chronic right shoulder pain diagnosis, persistent right shoulder pain, and long-term right shoulder pain clinical documentation and medical coding. Find information on healthcare, treatment, and ICD-10 codes related to right shoulder pain. Learn about causes, symptoms, and management of chronic right shoulder discomfort for accurate medical records and billing.
Also known as
Rotator cuff syndrome or tendinitis, right shoulder
Pain and inflammation in the rotator cuff tendons of the right shoulder.
Pain in right shoulder
Unspecified pain localized to the right shoulder region.
Pain in right upper limb
Chronic pain affecting the right arm, not otherwise specified.
Right glenohumeral osteoarthritis
Degenerative joint disease affecting the right shoulder joint.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is there a documented underlying cause for the chronic right shoulder pain?
Yes
Is the cause rotator cuff related?
No
Code M25.511 (Pain in right shoulder)
When to use each related code
| Description |
|---|
| Chronic right shoulder pain lasting > 3 months. |
| Right shoulder adhesive capsulitis. |
| Rotator cuff tear (right). |
Missing 'right' laterality can lead to incorrect coding and reimbursement issues. Impacts claims accuracy and compliance.
Miscoding chronic as acute pain can affect severity documentation, impacting medical necessity reviews and payment.
Coding 'pain' without specifying the underlying cause can result in claim denials. Requires thorough documentation for specificity.
Q: What are the most common differential diagnoses for chronic right shoulder pain lasting longer than 3 months in a 50-year-old patient?
A: Chronic right shoulder pain lasting more than 3 months in a 50-year-old patient presents a wide range of potential diagnoses. Rotator cuff tear, adhesive capsulitis (frozen shoulder), osteoarthritis, and degenerative labral tears are frequently encountered in this demographic. Less common, but important to consider, are diagnoses like calcific tendinitis, referred pain from the cervical spine or thoracic outlet syndrome, and inflammatory conditions like rheumatoid arthritis. A thorough clinical examination, including range of motion assessment, palpation, and specific provocative tests, is crucial to differentiate these conditions. Explore how imaging modalities, such as ultrasound or MRI, can further refine the diagnosis and guide appropriate management strategies.
Q: How can clinicians effectively differentiate between rotator cuff tear and frozen shoulder in patients presenting with chronic right shoulder pain and limited range of motion?
A: Distinguishing between rotator cuff tear and frozen shoulder, both presenting with chronic right shoulder pain and limited range of motion, requires careful evaluation. While both conditions restrict movement, rotator cuff tears typically exhibit more weakness during active abduction and external rotation, whereas frozen shoulder presents with global loss of both active and passive range of motion, especially external rotation. Pain patterns can also offer clues, with rotator cuff tears often causing pain with overhead activities and frozen shoulder causing more constant, diffuse pain. Consider implementing a combination of physical examination maneuvers, such as the Apley scratch test and the empty can test, alongside patient history, to aid in differentiation. Diagnostic imaging, particularly MRI, can confirm a rotator cuff tear, while arthrography may be helpful in assessing the capsular restriction in frozen shoulder.
Patient presents with chronic right shoulder pain, also described as persistent right shoulder pain, of six months duration. Onset was insidious, with no specific injury reported. Pain is described as a dull ache, occasionally sharp with movement, localized to the right shoulder joint and radiating down the lateral arm. Patient reports stiffness and limited range of motion, impacting activities of daily living such as dressing and reaching overhead. Aggravating factors include lifting objects and sleeping on the affected side. Alleviating factors include rest and over-the-counter analgesics such as ibuprofen. Patient denies any numbness, tingling, or weakness in the right hand or arm. Physical examination reveals tenderness to palpation over the right anterior and lateral shoulder, with crepitus noted on passive range of motion. Strength testing is 5/5 in the right upper extremity. Differential diagnosis includes rotator cuff tendinopathy, adhesive capsulitis, osteoarthritis, and referred pain from the cervical spine. Assessment: Chronic right shoulder pain (ICD-10 code M79.601). Plan: Order right shoulder X-ray to evaluate for bony abnormalities. Prescribe physical therapy for range of motion exercises and strengthening. Recommend ice and heat therapy for pain management. Patient education provided on proper body mechanics and activity modification. Follow-up scheduled in four weeks to reassess symptoms and treatment efficacy.