Find information on Traumatic Rotator Cuff Tear diagnosis, including ICD-10 codes (S46.0, M75.1), clinical documentation requirements, and healthcare resources. Learn about rotator cuff injury symptoms, treatment options, and medical coding guidelines for accurate reimbursement. Explore resources for physicians, coders, and other healthcare professionals related to rotator cuff tear documentation and coding best practices.
Also known as
Injuries to rotator cuff
Covers traumatic tears and other injuries to the rotator cuff.
Shoulder lesions
Includes rotator cuff syndromes like impingement or tendinitis, but not direct tears.
Injuries to shoulder and upper arm
Encompasses a broader range of shoulder injuries including fractures and dislocations.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the rotator cuff tear traumatic?
Yes
Full thickness tear?
No
Not a traumatic tear. See other guidelines for appropriate code.
When to use each related code
| Description |
|---|
| Traumatic rotator cuff tear |
| Rotator cuff tendinopathy |
| Shoulder impingement syndrome |
Missing right or left shoulder designation can lead to claim denials and inaccurate data reporting. Code requires laterality (ICD-10-CM).
Documentation must clearly distinguish acute, chronic, or acute on chronic tear for proper S46. ICD-10-CM coding demands acuity specificity.
Traumatic cause must be explicitly documented to support the S46. code. Unspecified rotator cuff tear codes may be incorrectly assigned without it.
Q: What are the most effective evidence-based conservative management strategies for acute traumatic rotator cuff tears in young athletes, and when is surgical intervention warranted?
A: Conservative management of acute traumatic rotator cuff tears in young athletes often involves a combination of rest, ice, compression, and elevation (RICE), alongside physical therapy focused on restoring range of motion and strengthening surrounding shoulder muscles. Evidence suggests early mobilization protocols can be beneficial. Nonsteroidal anti-inflammatory drugs (NSAIDs) can help manage pain and inflammation. However, surgical intervention is often warranted for complete tears, particularly in athletes relying heavily on overhead movements. Factors influencing surgical decisions include tear size, patient age, activity level, and chronicity of the injury. Explore how early surgical intervention can lead to improved outcomes in certain cases, especially for large or complex tears. Consider implementing validated functional assessments to gauge recovery progress and guide treatment decisions.
Q: How can I accurately differentiate a full-thickness rotator cuff tear from a partial tear or other shoulder pathologies like rotator cuff tendinopathy or labral tears using physical exam and imaging techniques?
A: Differentiating rotator cuff tear severity and associated pathologies requires a thorough clinical evaluation. Physical examination findings like weakness during specific rotator cuff muscle testing (e.g., empty can test, drop arm test), limited active range of motion, and palpable defects may suggest a tear. However, imaging studies are crucial for confirming the diagnosis and assessing tear size and location. MRI is the gold standard, providing detailed visualization of the rotator cuff tendons and surrounding structures. Ultrasound can be a cost-effective alternative for dynamic assessment and evaluating other pathologies like biceps tendinopathy or labral tears. Learn more about the specific MRI findings that can help differentiate partial versus full-thickness tears and distinguish rotator cuff tears from other shoulder conditions.
Patient presents with complaints of right shoulder pain following a fall onto an outstretched hand. Onset of pain was immediate and described as sharp and intense. Patient reports significant limitations in active range of motion, particularly with abduction and external rotation. Pain is exacerbated by overhead activities and sleeping on the affected side. Medical history includes hypertension, well-controlled with medication. Surgical history is unremarkable. Physical examination reveals tenderness to palpation over the right anterior and lateral shoulder, positive Neer and Hawkins impingement signs, and weakness with resisted abduction and external rotation. Full thickness rotator cuff tear is suspected. Differential diagnosis includes rotator cuff tendinopathy, shoulder impingement syndrome, and labral tear. Ordered MRI of the right shoulder to confirm diagnosis and assess the extent of the tear. Preliminary diagnosis: Traumatic rotator cuff tear, right shoulder. Plan to discuss surgical and non-surgical treatment options with the patient following MRI results. ICD-10 code S46.011A, right shoulder, initial encounter. CPT codes for evaluation and management will be determined based on time spent with the patient. Return to clinic scheduled in one week for review of imaging and discussion of treatment plan. Patient education provided regarding activity modification, ice, and over-the-counter pain management. Patient expressed understanding of instructions.