Subacromial Bursitis
Find information on subacromial bursitis diagnosis, including clinical documentation, medical coding, ICD-10 codes (M75.51), CPT codes for injections and aspirations, treatment options, and healthcare provider resources. Learn about symptoms, causes, and differential diagnosis of shoulder bursitis, rotator cuff impingement, and related conditions. This resource provides guidance for accurate medical coding and documentation for subacromial bursitis.
Inflammation of the bursa cushioning the shoulder joint.
Shoulder pain, especially with overhead reaching or lying on affected side. Stiffness, limited range of motion.
Overuse injuries, repetitive motions, trauma, rheumatoid arthritis, gout.
ICD-10 Code Families
Complete code families applicable to M75.50
When to use each related code
| Description | When to use |
|---|---|
| Shoulder bursa inflammation | Pain with overhead movement, tenderness over lateral shoulder, normal ROM. Exclude rotator cuff tear. |
| Rotator cuff tear | Shoulder weakness, pain with overhead movement, limited ROM. Consider MRI for confirmation. |
| Adhesive capsulitis | Stiff, painful shoulder with significantly restricted ROM in all directions. Gradual onset. |
Best-practice checklist
- ✓Document patient-reported shoulder pain
- ✓Physical exam: Limited ROM, tenderness
- ✓Painful Arc test positive documentation
- ✓Imaging: X-ray or MRI findings (optional)
- ✓Impingement tests (e.g., Neer, Hawkins)
Common pitfalls to avoid
Coding for subacromial bursitis requires specifying right, left, or bilateral. Unspecified laterality leads to claim denials and inaccurate data.
Subacromial impingement and bursitis often co-occur. Incorrectly coding impingement without bursitis impacts reimbursement and quality metrics.
Traumatic vs. non-traumatic bursitis requires distinct codes. Lack of documentation specifying etiology causes coding errors and compliance issues.
Best-practice tips
- 01Document specific bursa location (e.g., subacromial) for ICD-10 accuracy.
- 02Correlate physical exam findings (e.g., impingement tests) with imaging for M75.5 code.
- 03Specify symptom duration and severity to support the diagnosis and treatment plan.
- 04Avoid using 'bursitis' alone. Detail location and laterality for proper coding.
- 05Query physician for clarity if documentation lacks specifics for accurate CDI.
Step-by-step checklist
- 1
Verify painful arc during shoulder abduction range of motion
- 2
Palpate for subacromial tenderness ICD10 M75.5
- 3
Assess for impingement signs Neer and Hawkins tests
- 4
Evaluate for restricted active and passive ROM documentation
- 5
Rule out rotator cuff tear and other shoulder pathologies
Ready-to-paste narrative
Subacromial bursitis diagnosed. Patient presents with shoulder pain, specifically localized to the lateral aspect and aggravated by overhead activities. Symptoms include pain with abduction, external rotation, and impingement signs positive on physical exam (Neer and Hawkins tests). Pain reported as aching and intermittent, increasing in intensity with movement. Patient denies any specific trauma but reports gradual onset over several weeks, correlating with increased activity at work involving repetitive overhead lifting. Palpation reveals tenderness over the subacromial bursa. Range of motion is limited due to pain, with abduction actively limited to 100 degrees and passively limited to 120 degrees. Strength testing reveals mild weakness in supraspinatus and infraspinatus muscles. Differential diagnosis includes rotator cuff tear, adhesive capsulitis, and cervical radiculopathy. Working diagnosis of subacromial bursitis based on clinical presentation and examination findings. Treatment plan includes conservative management with NSAIDs for pain and inflammation, ice application, and physical therapy focusing on range of motion exercises and strengthening of the rotator cuff muscles. Patient education provided regarding activity modification and proper body mechanics. Follow-up scheduled in two weeks to assess response to treatment. ICD-10 code M75.51, right shoulder bursitis, and CPT codes for evaluation and management (e.g., 99203-99205 or 99212-99215 depending on complexity) will be used for billing and coding purposes. Prognosis is good with conservative treatment, and patient is expected to regain full function with appropriate management.
Clinical accuracy: This information is provided for documentation and coding guidance and should not replace professional medical judgment.
Coding standard: ICD-10-CM, current FY guidelines.