Find information on right shoulder supraspinatus tear diagnosis, ICD-10 codes (S46.011A, S46.011D, S46.011S), clinical documentation requirements, and treatment options for traumatic rotator cuff tears. Learn about shoulder pain assessment, MRI findings for supraspinatus tears, and surgical vs. non-surgical management of this common shoulder injury. Explore resources for healthcare professionals, including coding guidelines and best practices for accurate diagnosis and documentation of right shoulder supraspinatus tears due to trauma.
Also known as
Injury of shoulder and upper arm
Covers injuries to the shoulder, including rotator cuff tears.
Shoulder lesions
Includes rotator cuff syndromes and other shoulder soft tissue disorders.
Falls
If the tear was caused by a fall, this range codes the external cause.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the tear traumatic?
When to use each related code
| Description |
|---|
| Traumatic Supraspinatus Tear |
| Rotator Cuff Tear NOS |
| Shoulder Impingement Syndrome |
Using unspecified trauma codes like S46.0 without specifying the exact mechanism (e.g., fall, strain) leads to inaccurate data and potential claim denials.
Failing to document and code the affected side (right) with a laterality code (e.g., M75.111) can cause claim rejections and coding errors.
Lack of clear documentation specifying the acuteness or chronicity of the tear, partial or full thickness impacts code selection and reimbursement.
Patient presents with complaints of right shoulder pain, weakness, and limited range of motion following a traumatic incident (fall, sports injury, etc.). Onset of symptoms occurred on [date of onset]. The patient describes the pain as [character of pain: sharp, dull, aching, burning] and located in the anterolateral aspect of the shoulder, possibly radiating to the upper arm. Pain is exacerbated by overhead activities and abduction. Physical examination reveals tenderness to palpation over the right supraspinatus tendon insertion, positive Neer and Hawkins-Kennedy impingement tests, and weakness with resisted abduction and external rotation. Range of motion is restricted in abduction, flexion, and external rotation compared to the contralateral side. Differential diagnoses include rotator cuff tendinopathy, subacromial bursitis, adhesive capsulitis, and cervical radiculopathy. Diagnostic imaging (MRI right shoulder) was ordered and confirms a full-thickness tear of the right supraspinatus tendon. Assessment: Right shoulder supraspinatus tear due to trauma (ICD-10: S46.011A). Plan: Conservative management with physical therapy focused on range of motion exercises, strengthening, and pain management will be initiated. Patient education regarding activity modification and proper shoulder mechanics will be provided. Referral to orthopedic surgery for evaluation and consideration of surgical repair (rotator cuff repair CPT code 29827) will be made if conservative treatment fails to provide adequate relief within [timeframe]. Follow-up appointment scheduled in [timeframe] to assess response to treatment and discuss further management options.