Find information on Rotator Cuff Syndrome diagnosis, including clinical documentation, ICD-10 codes (M75.1-, S46.0-), medical coding guidelines, and healthcare resources. Learn about rotator cuff tear, impingement syndrome, supraspinatus tendinopathy, and other related shoulder conditions. Explore accurate medical coding for rotator cuff repair, subacromial decompression, and other treatment procedures. This resource supports physicians, coders, and healthcare professionals in accurately documenting and coding Rotator Cuff Syndrome.
Also known as
Rotator cuff syndromes
Includes rotator cuff tears, tendinitis, and impingement.
Injuries to rotator cuff
Covers traumatic rotator cuff injuries like sprains and strains.
Other specified shoulder lesions
May include rotator cuff related issues not specified elsewhere.
Unspecified shoulder lesion
Used when a more specific rotator cuff diagnosis isn't available.
Follow this step-by-step guide to choose the correct ICD-10 code.
Complete rotator cuff tear confirmed?
Yes
Traumatic tear?
No
Partial rotator cuff tear?
When to use each related code
| Description |
|---|
| Shoulder pain with weakness |
| Shoulder impingement |
| Adhesive capsulitis |
Coding rotator cuff syndrome without specifying affected side (right, left, bilateral) leads to claim denials and inaccurate data.
Using unspecified codes (e.g., M75.10) when more specific diagnoses like tear or tendinitis are documented impacts reimbursement and quality metrics.
Lack of supporting clinical documentation for rotator cuff syndrome diagnosis, including physical exam findings and imaging results, increases audit risk and claim rejection probability.
Patient presents with complaints consistent with rotator cuff syndrome. Symptoms include shoulder pain, notably with abduction and external rotation, as well as pain at night. The patient reports difficulty with overhead activities and limitations in functional range of motion. Onset of symptoms began approximately [timeframe] and is attributed to [possible cause, e.g., overuse, injury]. Physical examination reveals tenderness to palpation over the rotator cuff tendons, positive impingement signs (Neer, Hawkins-Kennedy), and weakness with resisted external rotation and abduction. Differential diagnosis includes rotator cuff tear, adhesive capsulitis, and bicipital tendinitis. Assessment suggests rotator cuff tendinopathy as the most likely diagnosis. Initial treatment plan includes conservative management with nonsteroidal anti-inflammatory drugs (NSAIDs), ice, and physical therapy focusing on range of motion and strengthening exercises. Patient education provided regarding activity modification and proper body mechanics. Follow-up scheduled in [timeframe] to assess response to treatment. ICD-10 code M75.11 will be used for right shoulder and M75.12 for left shoulder. If symptoms do not improve, further investigation with MRI may be considered to evaluate for rotator cuff tear. Medical necessity for treatment documented.