ICD-10 Coding for Impingement Syndrome Right Shoulder(M75.41)
Complete ICD-10-CM coding and documentation guide for Impingement Syndrome Right Shoulder. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Impingement Syndrome Right Shoulder
M75.4-M75.41Primary Range
Disorders of bursae and tendons in shoulder region
This range includes codes for shoulder impingement syndromes, specifically focusing on laterality and specificity.
Key Information: ICD-10 code for impingement syndrome of right shoulder
Essential facts and insights about Impingement Syndrome Right Shoulder
Primary ICD-10-CM Code for impingement syndrome right shoulder
Decision Criteria
clinical Criteria
- Positive Hawkins or Neer test with imaging confirmation
documentation Criteria
- Documentation must specify 'right shoulder' and include clinical findings
Applicable To
- Subacromial impingement of right shoulder
Clinical Validation Requirements
- Positive Hawkins or Neer test
- MRI showing subacromial narrowing
Code-Specific Risks
- Incorrectly coding without confirming laterality
- Using this code without sufficient clinical documentation
Coding Notes
- Ensure documentation specifies 'right shoulder' and includes clinical tests and imaging results.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Pain in right shoulder
M25.511Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Impingement Syndrome Right Shoulder to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.41.
Impact
Clinical: May lead to incorrect treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Always include laterality in documentation, Review documentation for completeness
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with coding standards., Data Quality: Inaccurate clinical data recording.
Mitigation Strategy
Always specify laterality when coding for shoulder impingement.
Impact
Incomplete documentation can lead to audit risks.
Mitigation Strategy
Ensure all clinical findings and imaging results are documented.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Impingement Syndrome Right Shoulder, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Impingement Syndrome Right Shoulder
Use these documentation templates to ensure complete and accurate documentation for Impingement Syndrome Right Shoulder. These templates include all required elements for proper coding and billing.
Orthopedic Evaluation
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical exam findings
- Imaging results
- Diagnosis
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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