ICD-10 Coding for Shoulder Impingement(M75.41, M75.42)
Complete ICD-10-CM coding and documentation guide for Shoulder Impingement. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Shoulder Impingement
M75.4Primary Range
Impingement syndrome of shoulder
This range covers the primary codes for shoulder impingement, specifying laterality and including unspecified cases.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M75.41 | Impingement syndrome of right shoulder | Use when clinical and imaging findings confirm right shoulder impingement. |
|
| M75.42 | Impingement syndrome of left shoulder | Use when clinical and imaging findings confirm left shoulder impingement. |
|
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 right shoulder impingement
Essential facts and insights about Shoulder Impingement
Primary ICD-10-CM Codes for shoulder impingement
Decision Criteria
clinical Criteria
- Presence of positive Hawkins and Neer's tests with imaging confirmation.
Applicable To
- Right shoulder impingement
Excludes
- Rotator cuff tear (S46.91xA)
Clinical Validation Requirements
- Positive Hawkins test
- Positive Neer's sign
- Imaging showing reduced acromiohumeral distance
Code-Specific Risks
- Incorrectly coding as shoulder pain (M25.511) without confirming impingement.
Coding Notes
- Ensure documentation includes specific tests and imaging findings to support the diagnosis.
M75.42 - Impingement syndrome of left shoulder
Use when clinical and imaging findings confirm left shoulder impingement.
Applicable To
- Left shoulder impingement
Excludes
- Rotator cuff tear (S46.91xA)
Clinical Validation Requirements
- Positive Hawkins test
- Positive Neer's sign
- Imaging showing reduced acromiohumeral distance
Coding Notes
Ensure documentation includes specific tests and imaging findings to support the diagnosis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Shoulder Impingement 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 misdiagnosis., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials.
Mitigation Strategy
Ensure detailed documentation of clinical findings., Use templates to guide comprehensive documentation.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Document specific signs like positive Hawkins test to justify M75.41.
Impact
Using M75.40 without specifying laterality can trigger audits.
Mitigation Strategy
Always specify laterality when documenting shoulder impingement.
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 Shoulder Impingement, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Shoulder Impingement
Use these documentation templates to ensure complete and accurate documentation for Shoulder Impingement. These templates include all required elements for proper coding and billing.
Orthopedic evaluation for shoulder impingement
Specialty: OrthopedicsRequired Elements
- History of present illness
- Physical exam findings
- Imaging results
- Diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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