Find information on Rotator Cuff Rupture diagnosis including ICD-10 codes (M75.111, M75.112, M75.121, M75.122), clinical documentation requirements, differential diagnosis considerations, and common treatment options. Learn about rotator cuff tear symptoms, physical exam findings for rotator cuff injury, surgical repair, and post-operative care. This resource provides guidance on accurate medical coding and complete healthcare documentation for rotator cuff tears.
Also known as
Rotator cuff syndromes
Includes tears and tendinitis of rotator cuff muscles.
Injury of shoulder and upper arm
Covers various shoulder injuries, including rotator cuff tears from trauma.
Pain in shoulder
Can be used for pain associated with a rotator cuff tear if the tear itself isn't the focus.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the rotator cuff rupture traumatic?
When to use each related code
| Description |
|---|
| Rotator cuff tear |
| Shoulder impingement |
| Biceps tendinitis |
Coding rotator cuff rupture without specifying right, left, or bilateral shoulder can lead to claim denials and inaccurate reporting. Use specific laterality codes.
Incomplete documentation of acute vs. chronic rupture impacts code selection and reimbursement. CDI should query physicians for clarification.
Distinguishing traumatic ruptures from degenerative ones is crucial for accurate coding and affects injury-related statistics. Ensure proper documentation.
Patient presents with complaints of shoulder pain, consistent with symptoms of a rotator cuff tear. Onset of pain was [Onset - e.g., gradual, sudden], [Duration - e.g., 2 weeks, 3 months] ago, described as [Pain Quality - e.g., sharp, dull, aching] and located [Pain Location - e.g., anterior shoulder, lateral shoulder, radiating down the arm]. Pain is aggravated by [Aggravating Factors - e.g., overhead activities, lifting, sleeping on affected side] and relieved by [Relieving Factors - e.g., rest, ice, over-the-counter pain medication]. Patient reports [Degree of Functional Limitation - e.g., difficulty with dressing, reaching overhead, lifting objects]. Physical examination reveals [Positive Findings - e.g., tenderness to palpation over the affected shoulder, limited range of motion, positive Neer impingement sign, positive Hawkins-Kennedy test, weakness with external rotation and abduction]. Differential diagnosis includes rotator cuff tendinopathy, shoulder impingement syndrome, adhesive capsulitis, and cervical radiculopathy. Preliminary diagnosis of rotator cuff rupture is suspected based on clinical presentation and physical exam findings. Ordered [Imaging Studies - e.g., shoulder x-ray, MRI of the shoulder] to confirm the diagnosis and assess the extent of the tear. Treatment plan includes [Conservative Management - e.g., rest, ice, NSAIDs, physical therapy referral] or [Surgical Options - e.g., rotator cuff repair] depending on imaging results and patient's response to conservative management. ICD-10 code [Appropriate ICD-10 code - e.g., M75.111, M75.112, S46.001A, S46.001D] is considered. Patient education provided regarding rotator cuff injury, recovery expectations, and potential complications. Follow-up appointment scheduled in [Duration - e.g., 2 weeks, 4 weeks] to review imaging results and discuss further management.