Find information on rotator cuff tear diagnosis, including clinical documentation, ICD-10 codes (M75.1, S46.0), medical coding, and healthcare resources. Learn about rotator cuff injuries, shoulder pain, subscapularis tear, supraspinatus tear, infraspinatus tear, and teres minor tear diagnosis and treatment. This resource provides details on rotator cuff pathology, MRI findings for rotator cuff tears, and accurate medical coding for optimal reimbursement. Explore rotator cuff tear symptoms, differential diagnosis, and best practices for healthcare professionals.
Also known as
Rotator cuff syndromes
Includes tears and other disorders of the rotator cuff muscles or tendons.
Injury of shoulder and upper arm
Covers various shoulder injuries, including potential rotator cuff tears from trauma.
Pain in shoulder
May be used if pain is the primary symptom of a rotator cuff tear, pending confirmation.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the tear traumatic?
Yes
Which shoulder?
No
Full or partial tear?
When to use each related code
| Description |
|---|
| Rotator cuff tear |
| Rotator cuff tendinitis |
| Shoulder impingement |
Coding rotator cuff tear without specifying affected side (right, left, bilateral) leads to claim rejection and inaccurate data.
Failing to document full thickness, partial thickness, or other tear specifics impacts coding accuracy and reimbursement.
Incorrectly coding traumatic tears as atraumatic or vice versa leads to coding errors and compliance issues.
Patient presents with complaints of shoulder pain consistent with a possible rotator cuff tear. Symptoms include pain with abduction and external rotation, weakness in the affected shoulder, and difficulty sleeping on the affected side. Onset of pain was reported as [gradual/acute] following [mechanism of injury, e.g., lifting heavy object, fall, repetitive overhead activity]. Physical examination revealed [positive/negative] Neer impingement sign, [positive/negative] Hawkins-Kennedy test, and limited range of motion. Palpable tenderness was noted over the [anterior/lateral/posterior] aspect of the shoulder. Strength testing demonstrated [grade, e.g., 4/5, 3/5] strength in abduction and external rotation compared to the contralateral side. Differential diagnosis includes rotator cuff tendinopathy, shoulder impingement syndrome, adhesive capsulitis, and cervical radiculopathy. Imaging studies, such as MRI of the shoulder, are recommended to confirm the diagnosis and assess the extent of the tear, including full-thickness tear, partial-thickness tear, and the involvement of specific tendons, such as supraspinatus, infraspinatus, teres minor, and subscapularis. Initial treatment plan includes conservative management with rest, ice, compression, elevation (RICE), nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy focusing on range of motion and strengthening exercises, and activity modification. Patient education provided regarding rotator cuff injury, recovery expectations, and pain management strategies. Referral to orthopedic surgery will be considered if conservative treatment fails to provide adequate relief or if significant functional limitations persist. Follow-up scheduled in [timeframe, e.g., 2 weeks] to assess response to treatment. ICD-10 code: [appropriate ICD-10 code, e.g., M75.111 - Rotator cuff tear or rupture, right shoulder].