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.
Also known as
Shoulder bursitis
Inflammation of bursae around the shoulder joint.
Rotator cuff syndrome
Shoulder pain involving rotator cuff tendons and bursa.
Other shoulder lesions
Includes other specified shoulder disorders, not elsewhere classified.
Shoulder lesion, unspecified
Unspecified disorder of the shoulder joint and surrounding structures.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the subacromial bursitis specified as traumatic?
When to use each related code
| Description |
|---|
| Shoulder bursa inflammation |
| Rotator cuff tear |
| Adhesive capsulitis |
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.
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.