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M75.100
ICD-10-CM
Rotator Cuff Tear

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

Shoulder Tendon Tear
Supraspinatus Tear

Diagnosis Snapshot

Key Facts
  • Definition : Rip in shoulder muscles and tendons causing pain and weakness.
  • Clinical Signs : Shoulder pain, weakness, limited motion, clicking or popping sound.
  • Common Settings : Sports injuries, falls, repetitive overhead activities, age-related degeneration.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC M75.100 Coding
M75.1-

Rotator cuff syndromes

Covers various rotator cuff tears and other related disorders.

S36.-

Injury of shoulder and upper arm

Includes traumatic shoulder injuries that may involve rotator cuff tears.

M25.5-

Pain in joint

Can be used for shoulder pain related to a rotator cuff tear if the tear itself isn't the primary focus.

Code-Specific Guidance

Decision Tree for

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?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Rotator cuff tear
Rotator cuff tendinopathy
Adhesive capsulitis

Documentation Best Practices

Documentation Checklist
  • Rotator cuff tear diagnosis documented
  • Laterality (left/right shoulder) specified
  • Tear size and location described
  • Symptoms and physical exam findings
  • ICD-10 code (e.g., S76.0, M75.1) present

Coding and Audit Risks

Common Risks
  • Unspecified Laterality

    Coding rotator cuff tear without specifying right, left, or bilateral shoulder leads to claim denials and inaccurate data.

  • Partial vs Full Tear

    Incorrectly coding partial tear as full tear or vice versa impacts reimbursement and quality reporting. CDI crucial for accurate documentation.

  • Traumatic vs Atraumatic

    Failing to distinguish traumatic vs. atraumatic tear causes coding errors. ICD-10 requires proper 7th character for injury mechanism.

Mitigation Tips

Best Practices
  • Document precise tear size, location, and chronicity for accurate ICD-10 coding (S46.0-).
  • Use standardized terminology for rotator cuff tear diagnosis in clinical documentation to improve CDI.
  • Ensure complete documentation of physical exam findings, imaging results, and prior treatments for compliance.
  • Query physicians for clarification if documentation lacks detail impacting code selection and reimbursement.
  • Review operative reports for consistency with pre-op diagnosis and post-op coding for healthcare compliance.

Clinical Decision Support

Checklist
  • Hx: Pain, weakness, limited ROM, catching/clicking
  • PE: Assess ROM, strength, impingement/special tests
  • Imaging: Consider X-ray, ultrasound, or MRI
  • Document tear size, location, and chronicity
  • ICD-10: M75.1xx, S46.0xx CPT: 23410-29828

Reimbursement and Quality Metrics

Impact Summary
  • Rotator cuff tear reimbursement hinges on accurate coding (ICD-10: M75.1-, S46.-) and documentation for optimal payer contracts.
  • Coding quality directly impacts rotator cuff tear claims denial rates. Correct CPT codes (e.g., 29827, 23410) are crucial.
  • Hospital reporting on rotator cuff tear surgery outcomes affects quality metrics like readmission rates and patient satisfaction scores.
  • Proper documentation and coding of rotator cuff tear diagnoses influence value-based reimbursement models and pay-for-performance programs.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code tear size, M75.1xx
  • Document abduction weakness
  • Specify partial/full thickness
  • ICD-10 Rotator Cuff Tear codes
  • Confirm laterality for M75.1xx

Documentation Templates

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.
Rotator Cuff Tear - AI-Powered ICD-10 Documentation