Find information on Supraspinatus Tear diagnosis including ICD-10 code M75.11, clinical documentation requirements, rotator cuff injury symptoms, shoulder pain treatment, MRI findings for Supraspinatus Tendinopathy, and effective physical therapy exercises. Learn about Supraspinatus Tear repair surgery, postoperative care, and common healthcare coding guidelines for accurate medical billing. This resource provides valuable insights for physicians, coders, and patients seeking information on Supraspinatus Tear diagnosis and management.
Also known as
Rotator cuff tear or rupture
Injury to the rotator cuff muscles or tendons in the shoulder.
Rotator cuff syndromes
Pain and limited movement due to shoulder impingement or tendinitis.
Injuries to the shoulder and upper arm
Includes various injuries like fractures, dislocations, and sprains.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the tear traumatic?
When to use each related code
| Description |
|---|
| Supraspinatus tendon tear |
| Rotator cuff tear |
| Adhesive capsulitis |
Coding a supraspinatus tear without specifying right, left, or bilateral can lead to claim denials and inaccurate data reporting. Use ICD-10 laterality codes.
Lack of sufficient documentation specifying the type of tear (full-thickness, partial-thickness) impacts accurate code assignment and reimbursement.
Failing to distinguish between a traumatic tear (S46) and an atraumatic/degenerative tear (M75.1) leads to coding errors and impacts quality metrics.
Patient presents with complaints of shoulder pain, consistent with a suspected supraspinatus tear. Symptoms include pain localized to the lateral aspect of the shoulder, exacerbated by abduction and external rotation. Onset of pain was gradual or acute, potentially related to a specific injury or repetitive overhead activities. Pain intensity is reported as mild, moderate, or severe, impacting activities of daily living such as reaching, lifting, and sleeping. Physical examination reveals tenderness to palpation over the greater tuberosity, positive Neer and Hawkins-Kennedy impingement tests, and limited active range of motion. Strength testing may demonstrate weakness in abduction and external rotation. Differential diagnosis includes rotator cuff tendinopathy, subacromial bursitis, adhesive capsulitis, and cervical radiculopathy. Diagnostic imaging, such as an MRI or ultrasound, is ordered to confirm the diagnosis of supraspinatus tear and assess the degree of tearing, including partial-thickness tear, full-thickness tear, or massive rotator cuff tear. Treatment plan may include conservative management with rest, ice, compression, elevation, physical therapy focusing on range of motion and rotator cuff strengthening exercises, and nonsteroidal anti-inflammatory drugs (NSAIDs). Corticosteroid injections may be considered for pain management. Surgical intervention, such as arthroscopic rotator cuff repair, may be indicated for full-thickness tears, failed conservative management, or significant functional limitations. Patient education provided regarding activity modification, proper body mechanics, and expected recovery time. Follow-up appointment scheduled to assess treatment response and adjust plan as needed. ICD-10 code M75.11 (Rotator cuff tear or rupture, right shoulder) or M75.12 (Rotator cuff tear or rupture, left shoulder) will be used, with additional codes as appropriate to reflect the specific findings and treatment provided. CPT codes will be determined based on the procedures performed, such as injection, aspiration, or surgical repair.