Find information on right shoulder conditions, including rotator cuff tear, frozen shoulder, shoulder impingement, arthritis, bursitis, and labral tear. Learn about diagnosis codes (ICD-10), clinical documentation improvement for accurate medical coding, and healthcare resources for right shoulder pain, instability, and limited range of motion. This resource provides guidance for physicians, coders, and other healthcare professionals on proper terminology and documentation for right shoulder conditions.
Also known as
Rotator cuff syndrome or tear, right shoulder
Pain and limited movement due to rotator cuff problems in the right shoulder.
Dislocation of right shoulder
Separation of the humerus from the scapula in the right shoulder joint.
Pain in right shoulder
Localized pain in the right shoulder, unspecified cause.
Other specified disorders right shoulder
Various specified conditions affecting the right shoulder not covered elsewhere.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the condition traumatic?
Yes
Fracture?
No
Rotator cuff tear?
When to use each related code
| Description |
|---|
| Rotator cuff tear |
| Shoulder impingement |
| Adhesive capsulitis |
Coding right shoulder conditions without specifying laterality can lead to inaccurate claims and denials. Use ICD-10 codes like S40.001A for clarity.
Inconsistent documentation of rotator cuff tears can cause inaccurate coding. Ensure specificity for full-thickness (S46.0) vs. partial tears (S46.1).
Vague descriptions of right shoulder pain or injury can lead to undercoding. Clear documentation of diagnosis, like adhesive capsulitis (M75.011), is crucial for accurate reimbursement.
Q: What are the key differential diagnoses to consider when a patient presents with chronic right shoulder pain and limited range of motion?
A: Chronic right shoulder pain with limited range of motion can stem from various conditions, making accurate differential diagnosis crucial. The most common culprits include rotator cuff tears, adhesive capsulitis (frozen shoulder), osteoarthritis, and glenohumeral instability. Less common but important considerations are labral tears, acromioclavicular joint arthritis, and nerve impingement syndromes. Accurate diagnosis relies on a thorough history, physical exam including specific tests like the Neer and Hawkins-Kennedy tests, and imaging studies such as X-rays, MRI, or ultrasound. Explore how a systematic approach to these diagnostic tools can improve patient outcomes and avoid misdiagnosis. Consider implementing standardized assessment protocols to ensure consistent and thorough evaluations of shoulder pain patients.
Q: How can I effectively differentiate between rotator cuff tendinopathy and a full-thickness rotator cuff tear in my clinical practice?
A: Differentiating between rotator cuff tendinopathy and a full-thickness rotator cuff tear requires careful evaluation. While both present with right shoulder pain and weakness, subtle differences can aid diagnosis. Tendinopathy usually involves pain with activity that resolves with rest, whereas a full-thickness tear may cause persistent pain and significant weakness, especially with abduction and external rotation. A thorough physical exam, including strength testing and special tests like the Drop Arm test and Empty Can test, provides valuable insights. Imaging, particularly MRI, is essential for confirming the diagnosis and assessing tear size and location. Learn more about the latest evidence-based guidelines for diagnosing and managing rotator cuff pathology to enhance your clinical practice.
Patient presents with complaints of right shoulder pain, stiffness, and limited range of motion. Onset of symptoms occurred gradually over the past [duration] and is aggravated by [activities causing aggravation]. Patient denies any specific injury or trauma to the right shoulder. Pain is described as [character of pain: e.g., sharp, aching, burning] and located [location of pain: e.g., anterior, posterior, lateral] with radiation to [radiation pattern if any]. Patient reports difficulty with [specific activities of daily living affected: e.g., reaching overhead, lifting, sleeping]. Medical history includes [relevant medical history: e.g., hypertension, diabetes, previous shoulder injuries]. Surgical history includes [relevant surgical history]. Current medications include [list of medications]. Allergies include [list of allergies]. Physical examination reveals [objective findings: e.g., tenderness to palpation, crepitus, muscle atrophy, positive impingement tests, limited abduction and external rotation]. Right shoulder range of motion is [degrees of motion for flexion, abduction, internal and external rotation]. Neurovascular examination is intact. Assessment includes [differential diagnoses: e.g., rotator cuff tear, rotator cuff tendinitis, shoulder impingement syndrome, frozen shoulder, osteoarthritis, adhesive capsulitis]. Impression is [most likely diagnosis based on exam findings]. Plan includes [diagnostic tests if needed: e.g., X-ray, MRI, ultrasound], [treatment plan: e.g., physical therapy, pain management with NSAIDs, corticosteroid injection, referral to orthopedics for surgical evaluation], and patient education on [relevant topics: e.g., activity modification, home exercises]. Follow-up scheduled in [duration] to assess response to treatment.