Find information on shoulder pain diagnosis, including ICD-10 codes, clinical documentation requirements, differential diagnosis, and common causes like rotator cuff tear, frozen shoulder, and shoulder impingement. Learn about evaluation, treatment options, and medical coding best practices for accurate reimbursement. Explore resources for healthcare professionals on managing shoulder pain and related conditions such as bursitis, arthritis, and tendonitis.
Also known as
Other soft tissue disorders
Includes rotator cuff syndromes and other shoulder pain.
Joint derangements
Covers shoulder instability and dislocations causing pain.
Injuries to shoulder and upper arm
Includes fractures and sprains resulting in shoulder pain.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the shoulder pain traumatic in origin?
Yes
Is there a fracture?
No
Is there rotator cuff tear/impingement?
When to use each related code
| Description |
|---|
| Shoulder pain |
| Rotator cuff tear |
| Adhesive capsulitis |
Coding shoulder pain as unspecified (M79.609) without documenting specific details like laterality or underlying cause leads to inaccurate coding and lost revenue.
Confusing rotator cuff tear (S46) with other shoulder conditions or not specifying the tear type (partial/full) can cause claim denials and compliance issues.
Failing to document a traumatic cause of shoulder pain (e.g., fracture, dislocation) impacts accurate coding and reimbursement for associated procedures.
Patient presents with shoulder pain, the chief complaint being discomfort in the rightleft shoulder region. Onset of pain is described as gradualacuteinsidious and began approximately duration ago, potentially related to activitymechanism of injury. Patient reports associated symptoms of stiffness, limited range of motion, weakness, clickingpoppingcrepitus, numbnesstingling radiating down the arm, and night pain interfering with sleep. Pain is characterized as aching, sharp, burning, throbbing, and is aggravated by movement overhead activityliftingreaching. Alleviating factors include rest, ice, and over-the-counter pain relievers such as ibuprofen or acetaminophen. Medical history includes relevant conditions such as rotator cuff tear, frozen shoulderadhesive capsulitis, shoulder impingement syndrome, osteoarthritis, rheumatoid arthritis, labral tear, bicep tendonitis, bursitis, and previous shoulder injuries or surgeries. Family history is notablepositive for relevant musculoskeletal conditions. Social history includes occupation, level of activity, and dominant hand. Physical examination reveals tenderness to palpation over the affected area, limited active and passive range of motion, muscle weaknessatrophy, and positive special tests such as the Neer test, Hawkins-Kennedy test, Empty Can test, and Apprehension test. Differential diagnoses include rotator cuff tear, shoulder impingement, frozen shoulder, osteoarthritis, and referred pain from the cervical spine. Initial treatment plan includes conservative management with rest, ice, compression, elevation RICE, nonsteroidal anti-inflammatory drugs NSAIDs, physical therapy, and activity modification. Imaging studies such as X-ray, MRI, or ultrasound may be indicated to further evaluate the underlying cause of the shoulder pain. Patient education provided on proper body mechanics, pain management strategies, and follow-up care. Referral to orthopedics or pain management may be considered if symptoms persist or worsen. Follow-up appointment scheduled in number weeks for reassessment and discussion of further management options.