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
Dislocation of shoulder
Includes labral tears often associated with shoulder dislocations.
Internal derangement of joint
Covers various internal joint problems, including labral tears.
Other injuries of shoulder
A more general category for shoulder injuries when a more specific code isn't available.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the labrum tear traumatic?
Yes
Shoulder location?
No
Shoulder location?
When to use each related code
Description |
---|
Labrum Tear |
SLAP Tear |
Rotator Cuff Tear |
Coding labrum tear without specifying right, left, or bilateral can lead to claim denials and inaccurate data reporting. Use appropriate laterality codes.
Failing to specify shoulder, hip, or other anatomical location of labrum tear impacts coding accuracy and reimbursement. Ensure specific site coding.
Incorrectly coding traumatic vs. degenerative labrum tears affects quality metrics and reimbursement. Document etiology for proper code selection.
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.