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
Dislocation of shoulder
Includes shoulder subluxation and labral tears.
Rotator cuff syndromes
Often associated with labral tears but not always.
Pain in shoulder region
A general category if specific tear details are lacking.
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?
When to use each related code
Description |
---|
Right Shoulder Labral Tear |
Right Shoulder Impingement |
Right Shoulder Instability |
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.
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.
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).
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.