Find information on rotator cuff tear diagnosis, including ICD-10 codes (M75.1, S46.0), clinical documentation requirements, and common symptoms like shoulder pain, weakness, and limited range of motion. Learn about rotator cuff injury treatment options, physical therapy, and surgical repair procedures. This resource provides healthcare professionals with essential information for accurate medical coding and comprehensive patient care related to rotator cuff tears.
Also known as
Rotator cuff syndromes
Covers various rotator cuff tears and other related disorders.
Injury of shoulder and upper arm
Includes traumatic shoulder injuries that may involve rotator cuff tears.
Pain in joint
Can be used for shoulder pain related to a rotator cuff tear if the tear itself isn't the primary focus.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the rotator cuff tear traumatic?
Yes
Which shoulder?
No
Which shoulder?
When to use each related code
Description |
---|
Rotator cuff tear |
Rotator cuff tendinopathy |
Adhesive capsulitis |
Coding rotator cuff tear without specifying right, left, or bilateral shoulder leads to claim denials and inaccurate data.
Incorrectly coding partial tear as full tear or vice versa impacts reimbursement and quality reporting. CDI crucial for accurate documentation.
Failing to distinguish traumatic vs. atraumatic tear causes coding errors. ICD-10 requires proper 7th character for injury mechanism.
Patient presents with complaints consistent with rotator cuff tear, including shoulder pain, weakness, and limited range of motion. Onset of symptoms began approximately [duration] ago and is described as [character of pain: sharp, dull, aching, etc.] The pain is located [location of pain: anterior, posterior, lateral shoulder, etc.] and radiates to [radiation pattern: upper arm, neck, etc.]. Aggravating factors include [activities that worsen pain: lifting, reaching overhead, sleeping on affected side, etc.] Alleviating factors include [activities that lessen pain: rest, ice, over-the-counter pain relievers, etc.]. Patient reports [impact on daily activities: difficulty dressing, driving, working, etc.]. Physical examination reveals [positive or negative findings: tenderness to palpation, positive Neer impingement sign, positive Hawkins-Kennedy test, limited active and passive range of motion, muscle atrophy, crepitus, etc.]. Diagnostic imaging, including [imaging modalities: X-ray, MRI, ultrasound], was ordered to confirm the diagnosis and assess the extent of the tear. Differential diagnoses considered include rotator cuff tendinitis, impingement syndrome, frozen shoulder, and cervical radiculopathy. Assessment: Rotator cuff tear (ICD-10 code: M75.1). Plan: Conservative management will be initiated, including rest, ice, compression, elevation (RICE), nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy focusing on range of motion and strengthening exercises. Patient education provided regarding proper body mechanics and activity modification. Surgical intervention, such as rotator cuff repair, will be considered if conservative treatment fails to provide adequate symptom relief. Follow-up appointment scheduled in [timeframe] to reassess progress and adjust treatment plan as needed.