Facebook tracking pixelRight Shoulder Labral Tear - AI-Powered ICD-10 Documentation
S43.421
ICD-10-CM
Right Shoulder Labral Tear

Find information on Right Shoulder Labral Tear diagnosis, including clinical documentation, medical coding, ICD-10 codes, CPT codes, and healthcare resources. Learn about labral tear symptoms, treatment options, and SLAP tear diagnosis. Explore resources for physicians, coders, and other healthcare professionals related to Right Shoulder Labral Tear documentation and coding best practices. This resource covers relevant information for accurate medical record keeping and billing related to Right Shoulder Labral Tears.

Also known as

SLAP Tear
Superior Labrum Anterior and Posterior Tear

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S43.421 Coding
S43.4-

Dislocation of shoulder

Includes shoulder subluxation and labral tears.

M75.1-

Rotator cuff syndromes

Often associated with labral tears but not always.

M25.2-

Pain in shoulder region

A general category if specific tear details are lacking.

Code-Specific Guidance

Decision Tree for

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

Is the labral tear traumatic?

  • Yes

    Is it anterior?

  • No

    Is it anterior?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right Shoulder Labral Tear
Right Shoulder Impingement
Right Shoulder Instability

Documentation Best Practices

Documentation Checklist
  • Document mechanism of injury or repetitive strain.
  • Specify location of tear (anterior, posterior, superior, inferior).
  • Describe symptoms: pain, clicking, popping, instability, weakness.
  • Include physical exam findings: range of motion, tenderness, special tests.
  • Note imaging results: MRI, MRA arthrogram findings confirming tear.

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding labral tear without specifying right shoulder can lead to claim denials or incorrect reimbursement. Use ICD-10 codes like S43.411A for accurate coding.

  • Missing Acuity Details

    Lack of documentation specifying the type and location of the tear (e.g., anterior, posterior, superior) may impact accurate coding and DRG assignment. CDI crucial.

  • Unclear Causality

    Failure to document traumatic vs. atraumatic tear can lead to coding errors and compliance issues. ICD-10-CM coding guidelines matter for proper code selection (e.g., M75.111, S43.411A).

Mitigation Tips

Best Practices
  • Accurate ICD-10 coding (S43.4-, M75.1-) for labral tear diagnoses.
  • Detailed HPI documentation improves shoulder pain CDI specificity.
  • Thorough PE findings (ROM, tenderness) support medical necessity.
  • Image studies (MRI, MRA) correlation for tear confirmation, compliance.
  • Pre-op & post-op PT documentation for optimized reimbursement.

Clinical Decision Support

Checklist
  • Hx: Shoulder pain, clicking, catching, instability (ICD-10: M75.111, S43.4)
  • PE: OBrien test, apprehension test, relocation test (SNOMED CT: 24897008)
  • Imaging: MRI arthrogram for labral tear confirmation (CPT: 73221)
  • R/O other shoulder pathologies: Rotator cuff tear, impingement (ICD-10: M75.1, M75.4)

Reimbursement and Quality Metrics

Impact Summary
  • Right Shoulder Labral Tear reimbursement hinges on accurate CPT coding (29807, 29806) impacting facility revenue.
  • ICD-10 codes (S43.4-, M75.1-) specificity crucial for proper claim processing and minimizing denials for labral tear.
  • Quality metrics like patient-reported outcome measures (PROMs) track functional improvement after labral repair surgery.
  • Timely documentation and coding of labral tear diagnoses improve hospital case mix index and overall reporting accuracy.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Code labral tear location
  • Document mechanism of injury
  • Specify acute or chronic tear
  • Include MRI findings for labrum
  • Consider associated pathologies

Documentation Templates

Patient presents with complaints of right shoulder pain, instability, clicking, and catching, consistent with a suspected right shoulder labral tear.  Onset of symptoms occurred [ timeframe e.g., gradually over the past three months] following [mechanism of injury e.g., a fall onto an outstretched hand, repetitive overhead throwing].  Pain is localized to the [location e.g., anterior, posterior, superior] aspect of the shoulder and is described as [character e.g., sharp, dull, aching].  The patient reports [frequency e.g., intermittent, constant] pain exacerbated by [aggravating factors e.g., overhead activities, reaching behind the back].  Physical examination reveals [positive or negative] tenderness to palpation over the [anatomical location e.g., anterior shoulder joint line].  Range of motion is [limited or within normal limits] with [degrees of motion if applicable e.g., abduction limited to 120 degrees].  Positive findings for [special tests e.g., OBrien's test, apprehension test, relocation test] suggest labral pathology.  Differential diagnosis includes rotator cuff tear, impingement syndrome, and biceps tendinopathy.  Imaging studies, including [imaging modality e.g., MRI arthrogram], are recommended to confirm the diagnosis and evaluate the extent of the labral tear.  Treatment plan includes [conservative or surgical management e.g., physical therapy focusing on rotator cuff strengthening, NSAIDs for pain management, surgical labral repair].  Patient education provided regarding activity modification, pain management strategies, and potential complications.  Follow-up scheduled in [timeframe e.g., two weeks] to reassess symptoms and discuss treatment progress.  ICD-10 code [appropriate ICD-10 code e.g., S43.411A] is considered for right shoulder labral tear.