Find comprehensive information on Shoulder Arthroscopy diagnosis, including clinical documentation, medical coding (CPT, ICD-10-CM), postoperative care, and rehabilitation protocols. Learn about rotator cuff repair, labral tear, SLAP lesion, impingement syndrome, and other shoulder conditions commonly addressed with arthroscopy. This resource provides valuable insights for healthcare professionals, coders, and patients seeking information on shoulder arthroscopy procedures, recovery, and medical billing.
Also known as
Arthroscopy, shoulder joint
Inspection of shoulder joint by arthroscopy.
Other procedures on shoulder
Includes other procedures like manipulation, drainage.
Other soft tissue disorders
Encompasses various shoulder conditions requiring arthroscopy.
Injuries, poisonings, external causes
Relevant for arthroscopy due to trauma or injury.
Follow this step-by-step guide to choose the correct ICD-10 code.
Was the arthroscopy diagnostic?
Yes
Any specific findings?
No
What was the procedure performed?
When to use each related code
| Description |
|---|
| Shoulder Arthroscopy |
| Rotator Cuff Tear |
| Shoulder Impingement |
Documentation lacks clear left or right shoulder designation, leading to coding errors and claim denials. Medical coding CDI must query for laterality.
Failure to code all distinct arthroscopic procedures performed (e.g., debridement, repair) impacting reimbursement. Healthcare compliance audits target this.
Arthroscopy performed for diagnostic purposes may be coded incorrectly if the findings dont support the pre-operative diagnosis. Medical coding and CDI review is essential.
Patient presents with chief complaint of right shoulder pain, consistent with symptoms of rotator cuff tear, impingement syndrome, or labral tear. Onset of pain was gradual, worsening over the past six months, and aggravated by overhead activities and lifting. Patient reports pain interfering with sleep and activities of daily living. Physical examination reveals tenderness to palpation over the anterior and lateral aspects of the shoulder, positive Neer and Hawkins impingement signs, and limited range of motion with forward flexion and abduction. Strength testing demonstrates mild weakness in abduction and external rotation. Differential diagnosis includes rotator cuff tendinopathy, subacromial bursitis, adhesive capsulitis, and glenohumeral arthritis. Diagnostic imaging, including shoulder x-ray and MRI arthrogram, was ordered to evaluate for rotator cuff pathology, labral tears, and other intra-articular abnormalities. Based on clinical findings and imaging results, the diagnosis of shoulder pathology requiring shoulder arthroscopy is made. Risks and benefits of surgical intervention, including rotator cuff repair, labral repair, and subacromial decompression, were discussed with the patient. Conservative management options, including physical therapy and nonsteroidal anti-inflammatory drugs (NSAIDs), were also reviewed. Patient elected to proceed with shoulder arthroscopy. Preoperative clearance and surgical scheduling were initiated. Follow-up appointment was scheduled for postoperative evaluation and rehabilitation plan. ICD-10 code M75.11 (Rotator cuff tear or rupture, right shoulder) and CPT code 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair) are anticipated, pending intraoperative findings.