Find information on right shoulder injury diagnosis, including clinical documentation, medical coding, ICD-10 codes, and common right shoulder pain symptoms. Learn about rotator cuff tear, frozen shoulder, shoulder impingement, AC joint separation, clavicle fracture, and other right shoulder conditions. Explore resources for healthcare professionals, including accurate medical coding guidelines and best practices for documenting right shoulder injuries for optimal reimbursement.
Also known as
Injuries to the shoulder and upper arm
Covers various injuries like sprains, dislocations, and fractures of the shoulder and upper arm.
Other soft tissue disorders
Includes conditions like rotator cuff tears or impingement syndromes affecting the shoulder.
Nerve root and plexus disorders
May be relevant if the shoulder injury involves nerve damage like brachial plexus injury.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the injury traumatic?
Yes
Fracture?
No
Overuse/Repetitive strain?
When to use each related code
| Description |
|---|
| Right Shoulder Injury |
| Rotator Cuff Tear, Right |
| Right Shoulder Dislocation |
Using unspecified codes like S99.9XXA when more specific diagnoses are documented, leading to lower reimbursement and audit scrutiny. ICD-10-CM, coding accuracy.
Missing or incorrect laterality (right vs. left) for shoulder injuries can cause claim denials and compliance issues. Medical coding, CDI, documentation.
Failing to document the specific type of trauma (fracture, dislocation, sprain, etc.) impacting accurate coding and appropriate care. Healthcare compliance, coding compliance.
Q: What are the most effective differential diagnosis strategies for differentiating between rotator cuff tear, frozen shoulder, and shoulder impingement in patients presenting with right shoulder injury?
A: Differentiating between rotator cuff tear, frozen shoulder (adhesive capsulitis), and shoulder impingement syndrome requires a multi-faceted approach. Begin with a thorough patient history, focusing on symptom onset, duration, and character. Pain with overhead activities or at night suggests rotator cuff pathology or impingement. Limited range of motion in all planes, especially external rotation, is a hallmark of frozen shoulder. Physical examination should assess active and passive range of motion, strength testing (especially supraspinatus, infraspinatus, and teres minor), and special tests like the Neer and Hawkins-Kennedy impingement tests, the Empty Can test for supraspinatus tears, and the Drop Arm test for rotator cuff tears. Imaging studies play a key role. X-rays can reveal bony abnormalities like osteoarthritis or spurs. MRI or ultrasound are more sensitive for soft tissue pathology, such as rotator cuff tears and labral tears, which can accompany impingement. Consider implementing a standardized physical exam protocol and explore how advanced imaging techniques like MR arthrography can improve diagnostic accuracy. Referral to a specialist should be considered if the diagnosis remains unclear or if surgical intervention is a possibility. Learn more about the specific diagnostic criteria for each condition to refine your assessment process.
Q: How do I effectively manage a patient with right shoulder pain and suspected rotator cuff tear, considering non-surgical treatment options and the appropriate timing for surgical referral?
A: Managing suspected rotator cuff tears involves a stepwise approach that starts with conservative measures. Initial management includes rest, ice, compression, and elevation (RICE), coupled with nonsteroidal anti-inflammatory drugs (NSAIDs) for pain control. Physical therapy plays a crucial role, focusing on range of motion exercises, strengthening of the rotator cuff and scapular stabilizers, and pain management modalities like ultrasound or iontophoresis. Corticosteroid injections can provide short-term pain relief and facilitate participation in physical therapy. Explore how incorporating patient education on activity modification and proper body mechanics can improve outcomes. Consider implementing a shared decision-making approach with the patient regarding surgical referral. Factors favoring surgical intervention include significant functional impairment despite conservative treatment for 3-6 months, acute traumatic tears, younger age, and high functional demands. Referral to an orthopedic surgeon specializing in shoulder surgery is warranted when non-operative measures fail to provide adequate relief or if the tear is deemed irreparable. Learn more about the latest evidence-based guidelines for rotator cuff tear management.
Patient presents with complaints of right shoulder pain. Onset of pain is reported as (acute, insidious, traumatic) and occurred (duration) ago. The pain is described as (sharp, dull, aching, burning, throbbing) and located in the (anterior, posterior, lateral, medial) aspect of the shoulder. Patient reports (aggravating factors: lifting, reaching overhead, sleeping on affected side) and (alleviating factors: rest, ice, heat, over-the-counter medications such as ibuprofen or acetaminophen). Patient denies (or reports) any numbness, tingling, or weakness in the right arm or hand. Physical examination reveals (tenderness to palpation, limited range of motion, crepitus, swelling, ecchymosis) in the right shoulder. Rotator cuff tear, shoulder impingement syndrome, frozen shoulder, shoulder arthritis, and shoulder bursitis are considered in the differential diagnosis. Right shoulder X-ray (positive, negative) for (fracture, dislocation, degenerative changes). Assessment: Right shoulder injury (specify: strain, sprain, tendinitis, bursitis, etc.). Plan: Patient education provided regarding activity modification, ice, and over-the-counter pain management. Prescription for (medication, if applicable) provided. Referral to physical therapy for range of motion and strengthening exercises. Follow-up appointment scheduled in (duration) to assess progress and consider further diagnostic testing such as MRI if symptoms persist or worsen. ICD-10 code (appropriate code based on specific injury) applied.