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S43.439A
ICD-10-CM
Labrum Tear

Find information on Labrum Tear diagnosis, including clinical documentation, medical coding, and healthcare resources. Learn about labrum tear symptoms, shoulder labrum tear ICD-10 code, SLAP tear treatment, and rotator cuff injury coding. This resource provides guidance for accurate labrum tear documentation and coding for medical professionals. Explore details on labrum tear MRI diagnosis, arthroscopic labrum repair, and relevant medical billing guidelines.

Also known as

Shoulder Labral Tear
SLAP Tear
Bankart Lesion

Diagnosis Snapshot

Key Facts
  • Definition : Rip in the shoulder cartilage ring stabilizing the ball-and-socket joint.
  • Clinical Signs : Shoulder pain, clicking or popping, instability, weakness, limited range of motion.
  • Common Settings : Sports injuries (baseball, football), falls, repetitive overhead activities.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S43.439A Coding
S43.4-

Dislocation of shoulder

Includes labral tears often associated with shoulder dislocations.

M24.4-

Internal derangement of joint

Covers various internal joint problems, including labral tears.

S43.8-

Other injuries of shoulder

A more general category for shoulder injuries when a more specific code isn't available.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the labrum tear traumatic?

  • Yes

    Shoulder location?

  • No

    Shoulder location?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Labrum Tear
SLAP Tear
Rotator Cuff Tear

Documentation Best Practices

Documentation Checklist
  • Labrum tear location (anterior, posterior, superior)
  • Mechanism of injury (traumatic, atraumatic)
  • Physical exam findings (e.g., clicking, pain, instability)
  • Imaging results (MRI, CT arthrogram) confirming tear
  • Pre-existing conditions or prior injuries to joint

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding labrum tear without specifying right, left, or bilateral can lead to claim denials and inaccurate data reporting. Use appropriate laterality codes.

  • Missing Anatomical Site

    Failing to specify shoulder, hip, or other anatomical location of labrum tear impacts coding accuracy and reimbursement. Ensure specific site coding.

  • Trauma vs. Degenerative

    Incorrectly coding traumatic vs. degenerative labrum tears affects quality metrics and reimbursement. Document etiology for proper code selection.

Mitigation Tips

Best Practices
  • Accurate ICD-10 coding (S43.4-): essential for compliance.
  • Detailed HPI, including mechanism of injury, improves CDI.
  • Document ROM, laxity tests for specificity, supporting medical necessity.
  • Image findings (MRI) correlation crucial for labrum tear diagnosis coding.
  • Thorough documentation speeds claims processing, prevents denials.

Clinical Decision Support

Checklist
  • 1. Verify shoulder pain, clicking, catching (ICD-10: M25.511, S43.4XXA)
  • 2. Assess OBrien's, Apprehension tests positive (SNOMED CT: 247005006)
  • 3. Confirm with MRI arthrogram imaging (CPT: 73221)
  • 4. Document mechanism of injury, limited ROM (ICD-10: S43.409A)

Reimbursement and Quality Metrics

Impact Summary
  • Labrum Tear reimbursement hinges on accurate ICD-10 (S43, M24.2) and CPT (29807, 29827) coding, impacting claim denial rates.
  • Proper coding of labrum tear type (anterior, posterior, SLAP) influences payment and quality metrics for surgical intervention.
  • Timely and specific documentation of labrum tear diagnosis and treatment impacts hospital case mix index and financial reporting.
  • Accurate labrum tear coding ensures appropriate DRG assignment, optimizing hospital reimbursement and quality scores.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code labrum tear location
  • Specify traumatic vs. atraumatic
  • Document clinical findings
  • Use M75.1 or S93.4 ICD-10
  • Confirm laterality for coding

Documentation Templates

Patient presents with complaints of shoulder pain, instability, clicking, catching, or locking sensation in the glenohumeral joint, consistent with a possible labrum tear.  Onset of symptoms reported as [acute/insidious] and related to [specific injury event or repetitive activity].  Pain is described as [sharp, dull, aching, burning] and located [anteriorly, posteriorly, superiorly] in the shoulder, potentially radiating to the [upper arm, neck].  Patient reports [difficulty with overhead activities, reaching across the body, sleeping on affected side].  Physical examination reveals [tenderness to palpation along the anterior/posterior/inferior glenoid rim, positive OBriens test, positive Apprehension test, positive Relocation test, limited range of motion].  Differential diagnosis includes rotator cuff tear, biceps tendinopathy, adhesive capsulitis, and glenohumeral osteoarthritis.  Imaging studies, including MRI arthrogram, may be ordered to confirm the diagnosis and evaluate the extent of the labral tear (SLAP tear, Bankart lesion).  Treatment plan may include conservative management with physical therapy focused on strengthening rotator cuff muscles, improving range of motion, and addressing shoulder instability.  If conservative treatment fails, surgical intervention, such as arthroscopic labral repair or debridement, may be considered.  Patient education provided on activity modification, pain management, and expected recovery time.  Follow-up appointment scheduled in [timeframe] to assess progress and adjust treatment plan as needed.
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