ICD-10 Coding for Rotator Cuff Tear Left Shoulder(M75.122, S46.012A)
Complete ICD-10-CM coding and documentation guide for Rotator Cuff Tear Left Shoulder. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Rotator Cuff Tear Left Shoulder
M75.1-M75.12Primary Range
Non-traumatic rotator cuff tear or rupture
This range includes codes for non-traumatic tears of the rotator cuff, specifying laterality and completeness of the tear.
Traumatic rupture of rotator cuff
This range covers traumatic tears of the rotator cuff, specifying laterality and acute nature.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M75.122 | Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic | Use when documentation specifies a complete, non-traumatic tear of the left shoulder. |
|
| S46.012A | Traumatic rupture of rotator cuff of left shoulder | Use when documentation specifies a traumatic event leading to the tear. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for non-traumatic rotator cuff tear left shoulder
Essential facts and insights about Rotator Cuff Tear Left Shoulder
Primary ICD-10-CM Codes for rotator cuff tear left shoulder
Decision Criteria
clinical Criteria
- MRI confirms full-thickness tear without trauma history.
documentation Criteria
- Patient history lacks any acute injury event.
Applicable To
- Chronic degenerative tear
- Full-thickness tear
Excludes
- Traumatic rupture of rotator cuff (S46.012A)
Clinical Validation Requirements
- MRI showing full-thickness tear
- No history of acute trauma
Code-Specific Risks
- Misclassification if trauma is not ruled out
Coding Notes
- Ensure documentation specifies non-traumatic nature and laterality.
S46.012A - Traumatic rupture of rotator cuff of left shoulder
Use when documentation specifies a traumatic event leading to the tear.
Applicable To
- Acute traumatic tear
- Injury-related rupture
Excludes
- Non-traumatic rotator cuff tear (M75.122)
Clinical Validation Requirements
- MRI showing acute tendon disruption
- Documented history of trauma
Coding Notes
Ensure trauma is explicitly linked to the tear in documentation.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Rotator Cuff Tear Left Shoulder to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.122.
Impact
Clinical: Inaccurate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Thorough patient interviews, Detailed documentation
Impact
Reimbursement: May lead to claim denials or reduced payments., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of patient records.
Mitigation Strategy
Always specify laterality, such as M75.122 for left shoulder.
Impact
Reimbursement: Incorrect coding can affect DRG assignment., Compliance: Risk of audit findings for incorrect coding., Data Quality: Misrepresents patient condition and treatment needs.
Mitigation Strategy
Verify trauma history and document clearly.
Impact
Misclassification of traumatic tears as non-traumatic.
Mitigation Strategy
Ensure thorough documentation of trauma history.
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 Rotator Cuff Tear Left Shoulder, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Rotator Cuff Tear Left Shoulder
Use these documentation templates to ensure complete and accurate documentation for Rotator Cuff Tear Left Shoulder. These templates include all required elements for proper coding and billing.
Chronic rotator cuff tear without trauma
Specialty: OrthopedicsRequired Elements
- Patient history
- Imaging results
- Clinical examination findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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