ICD-10 Coding for Shoulder Sprain(S43.401A, S43.51xA)
Complete ICD-10-CM coding and documentation guide for Shoulder Sprain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Shoulder Sprain
S43.4Primary Range
Sprain and strain of shoulder joint
This range includes specific codes for different types of shoulder sprains, including acromioclavicular and glenohumeral ligaments.
Sprain of acromioclavicular joint
This range is used for sprains specifically involving the acromioclavicular joint.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S43.401A | Sprain of unspecified ligament of right shoulder, initial encounter | Use when the specific ligament of the right shoulder is not identified, but a sprain is confirmed. |
|
| S43.51xA | Sprain of acromioclavicular joint of right shoulder, initial encounter | Use for confirmed sprains of the right acromioclavicular joint. |
|
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 shoulder sprain
Essential facts and insights about Shoulder Sprain
Primary ICD-10-CM Codes for shoulder sprain
Decision Criteria
clinical Criteria
- Presence of ligament tenderness and positive ligament-specific tests
coding Criteria
- Unspecified ligament of right shoulder
Applicable To
- Right shoulder ligament injury
Excludes
- Strain of muscle or tendon of shoulder (S46.0xxA)
Clinical Validation Requirements
- Physical exam showing tenderness over right shoulder ligaments
- MRI confirming ligament injury
Code-Specific Risks
- Risk of using unspecified codes leading to claim denials
Coding Notes
- Ensure laterality and encounter type are specified to avoid unspecified codes.
S43.51xA - Sprain of acromioclavicular joint of right shoulder, initial encounter
Use for confirmed sprains of the right acromioclavicular joint.
Applicable To
- Right AC joint sprain
Excludes
- Fracture of clavicle (S42.0xxA)
Clinical Validation Requirements
- Positive cross-body adduction test
- X-ray or MRI confirming AC joint involvement
Coding Notes
Ensure documentation specifies the AC joint and laterality.
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 Shoulder Sprain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S43.401A.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Use templates that prompt for specific ligament documentation., Train staff on importance of detailed documentation.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases the specificity and quality of clinical data.
Mitigation Strategy
Always specify the ligament and laterality to use specific codes.
Impact
High risk of audit if unspecified codes are used without justification.
Mitigation Strategy
Ensure documentation supports the use of specific codes.
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 Sprain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Shoulder Sprain
Use these documentation templates to ensure complete and accurate documentation for Shoulder Sprain. These templates include all required elements for proper coding and billing.
Acute shoulder sprain in emergency department
Specialty: Emergency MedicineRequired Elements
- Mechanism of injury
- Physical exam findings
- Imaging results
- Diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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