ICD-10 Coding for Left Bicep Tenodesis(M75.22)
Complete ICD-10-CM coding and documentation guide for Left Bicep Tenodesis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Bicep Tenodesis
M75.2-M75.22Primary Range
Disorders of bursa and tendons in shoulder region
This range includes codes for bicipital tendinitis, which is often associated with the need for tenodesis.
Key Information: ICD-10 code for left bicep tenodesis
Essential facts and insights about Left Bicep Tenodesis
Primary ICD-10-CM Code for left bicep tenodesis
Decision Criteria
clinical Criteria
- Confirmed inflammation of the biceps tendon via MRI
documentation Criteria
- Detailed operative report specifying tenodesis approach
Applicable To
- Inflammation of the biceps tendon
Excludes
- Tear of biceps tendon (S46.212A)
Clinical Validation Requirements
- MRI showing inflammation of the biceps tendon
- Physical exam findings such as tenderness over the bicipital groove
Code-Specific Risks
- Misdiagnosis if imaging does not confirm tendinitis
Coding Notes
- Ensure documentation supports the diagnosis of tendinitis through imaging and physical exam.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Repair of rotator cuff
23420Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Strain of muscle(s) and tendon(s) of the long head of biceps, left arm
S46.212ADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left Bicep Tenodesis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.22.
Impact
Clinical: Ambiguity in patient records., Regulatory: Potential for audit issues., Financial: Claim denials due to incomplete information.
Mitigation Strategy
Always include 'left' or 'right' in documentation., Use laterality modifiers in coding.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Verify the surgical approach in the operative report to select the correct CPT code.
Impact
Using the wrong CPT code for the procedure approach.
Mitigation Strategy
Ensure detailed operative reports and cross-check with coding guidelines.
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 Left Bicep Tenodesis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Bicep Tenodesis
Use these documentation templates to ensure complete and accurate documentation for Left Bicep Tenodesis. These templates include all required elements for proper coding and billing.
Open Biceps Tenodesis
Specialty: Orthopedic SurgeryRequired Elements
- Surgical approach
- Fixation method
- Concurrent procedures
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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