Find information on shoulder labrum tear diagnosis, including clinical documentation requirements, medical coding (ICD-10, CPT), and healthcare resources. Learn about SLAP tears, Bankart lesions, labral tear symptoms, and diagnostic tests like MRI arthrogram. This resource provides guidance for accurate medical coding and comprehensive clinical documentation of shoulder labrum tears for healthcare professionals.
Also known as
Dislocation of shoulder
Includes superior labrum anterior-posterior (SLAP) tears.
Internal derangement of joint
Covers unspecified shoulder internal derangements which can include labral tears.
Other injuries to shoulder
Can be used for labral tears not classified elsewhere.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the tear traumatic?
When to use each related code
| Description |
|---|
| Shoulder Labrum Tear |
| Rotator Cuff Tear |
| Shoulder Impingement |
Coding labrum tear without specifying right, left, or bilateral shoulder leads to claim rejections and inaccurate data.
Failure to document traumatic vs. atraumatic tear impacts code selection and appropriate treatment coding like surgery.
Lack of specific tear type (SLAP, Bankart) details hinders accurate coding, affecting reimbursement and quality metrics.
Patient presents with complaints of shoulder pain, instability, clicking, catching, or popping sensation in the shoulder joint. Onset of symptoms reported as [acute/gradual/insidious] and related to [specific injury/repetitive motion/unknown cause]. Patient describes pain as [sharp/dull/aching/burning] and located in the [anterior/posterior/lateral] aspect of the shoulder, potentially radiating to the [neck/upper arm/forearm]. Pain is [aggravated/alleviated] by [specific movements/activities/rest]. Physical examination reveals [positive/negative] apprehension test, [positive/negative] relocation test, and [positive/negative] O'Brien's test. Range of motion in the affected shoulder is [limited/normal] in [flexion/extension/abduction/internal rotation/external rotation] compared to the contralateral side. Palpation reveals [tenderness/crepitus] over the [anterior/posterior/lateral] aspect of the shoulder joint. Suspected shoulder labrum tear, likely [SLAP tear/Bankart lesion] based on mechanism of injury and clinical presentation. Differential diagnosis includes rotator cuff tear, shoulder impingement syndrome, biceps tendinopathy, and osteoarthritis. Ordered MRI arthrogram of the shoulder for definitive diagnosis. Treatment plan includes conservative management with physical therapy focusing on strengthening and stabilizing the shoulder girdle. Patient education provided on activity modification and pain management strategies. Surgical intervention, such as arthroscopic labral repair, will be considered if conservative treatment fails to provide adequate symptom relief. Follow-up scheduled in [timeframe] to assess response to treatment. ICD-10 code: [appropriate ICD-10 code, e.g., S43.431A for traumatic anterior labrum tear, right shoulder, initial encounter]. CPT codes for evaluation and management, imaging, and procedures will be documented accordingly.