Find information on Rotator Cuff Tendinopathy diagnosis, including ICD-10 codes (M75.1-, S46.0-), clinical documentation requirements, and healthcare coding guidelines. Learn about rotator cuff tears, impingement syndrome, and other related shoulder pain conditions. Explore resources for medical professionals on proper coding, billing, and documentation for rotator cuff tendinopathy treatment and rehabilitation. This resource offers valuable information for physicians, coders, and other healthcare providers.
Also known as
Rotator cuff syndromes
Includes rotator cuff tendinopathy and other related disorders.
Other specified shoulder lesions
Use when rotator cuff tendinopathy not specified elsewhere.
Unspecified shoulder lesion
Use when the specific shoulder lesion is not documented.
Pain in joint
Can be used if tendinopathy is causing pain in the shoulder joint.
Follow this step-by-step guide to choose the correct ICD-10 code.
Full rupture of rotator cuff?
Yes
Which tendon?
No
Impingement syndrome present?
When to use each related code
Description |
---|
Rotator cuff tendon pain/inflammation |
Rotator cuff tear |
Adhesive capsulitis |
Coding with unspecified rotator cuff tendinopathy (M75.1-) when documentation supports a more specific diagnosis (e.g., tear, calcific tendinitis) leads to undercoding and lost revenue.
Miscoding lateral epicondylitis (tennis elbow, M77.11) as rotator cuff tendinopathy due to similar symptoms can cause inaccurate reporting and claims denials.
Failing to document and code laterality (right, left, bilateral) for rotator cuff tendinopathy (M75.1-) impacts reimbursement and data accuracy for quality reporting.
Patient presents with complaints consistent with rotator cuff tendinopathy, also known as rotator cuff tendonitis, impacting the shoulder. Symptoms include shoulder pain, especially with overhead activities and at night, weakness, and limited range of motion. Onset of symptoms was gradual and reported as [duration]. Pain is localized to the [location: e.g., anterior, lateral, posterior] aspect of the shoulder and is described as [character: e.g., aching, sharp, burning]. Patient denies any specific injury but reports [activity/activities] that may have contributed to the condition. Physical examination reveals [positive/negative] Neer impingement sign, [positive/negative] Hawkins-Kennedy test, and painful arc of motion. Strength testing demonstrates [strength level] of the rotator cuff muscles. Differential diagnoses considered include rotator cuff tear, adhesive capsulitis (frozen shoulder), and cervical radiculopathy. Assessment is rotator cuff tendinopathy (ICD-10 code M75.1). Plan includes conservative management with rest, ice, compression, elevation (RICE), nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, physical therapy focusing on range of motion and rotator cuff strengthening exercises, and activity modification. Patient education provided on proper body mechanics and home exercise program. Follow-up appointment scheduled in [duration] to assess response to treatment. Referral to orthopedic specialist will be considered if symptoms do not improve with conservative management.