ICD-10 Coding for Supraspinatus Tear(M75.121, S46.011A)
Complete ICD-10-CM coding and documentation guide for Supraspinatus Tear. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Supraspinatus Tear
M75.1-Primary Range
Rotator cuff tear or rupture, not specified as traumatic
This range covers non-traumatic supraspinatus tears, including both partial and complete tears.
Injury of muscle(s) and tendon(s) of the rotator cuff of shoulder
This range is used for traumatic supraspinatus tears resulting from an acute injury.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M75.121 | Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic | Use for atraumatic, complete supraspinatus tears confirmed by imaging. |
|
| S46.011A | Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter | Use for acute, traumatic supraspinatus tears with documented injury. |
|
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 supraspinatus tear
Essential facts and insights about Supraspinatus Tear
Primary ICD-10-CM Codes for supraspinatus tear
Decision Criteria
clinical Criteria
- Confirmed full-thickness tear on imaging
documentation Criteria
- Documentation of atraumatic onset
Applicable To
- Full-thickness supraspinatus tear
Excludes
- Traumatic rotator cuff tear (S46.011-)
Clinical Validation Requirements
- MRI or ultrasound confirmation of full-thickness tear
- Chronic shoulder pain and weakness
Code-Specific Risks
- Misclassification as traumatic without proper documentation
Coding Notes
- Ensure documentation specifies 'atraumatic' and 'complete tear'.
S46.011A - Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter
Use for acute, traumatic supraspinatus tears with documented injury.
Applicable To
- Traumatic supraspinatus tear
Excludes
- Non-traumatic rotator cuff tear (M75.121)
Clinical Validation Requirements
- Documented mechanism of injury
- Acute pain onset following trauma
Coding Notes
Ensure documentation includes details of the traumatic event.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Pain in right shoulder
M25.511Differential 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 Supraspinatus Tear to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M75.121.
Impact
Clinical: Inaccurate representation of injury cause, Regulatory: Non-compliance with coding standards, Financial: Potential denial of claims
Mitigation Strategy
Always document the mechanism of injury, Include patient statements about the event
Impact
Reimbursement: Potential underpayment due to lack of specificity, Compliance: Non-compliance with coding guidelines, Data Quality: Decreased accuracy in clinical data
Mitigation Strategy
Specify the tear as partial or complete based on imaging.
Impact
Risk of audits due to incorrect specification of tear as partial or complete
Mitigation Strategy
Ensure thorough documentation and imaging confirmation.
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 Supraspinatus Tear, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Supraspinatus Tear
Use these documentation templates to ensure complete and accurate documentation for Supraspinatus Tear. These templates include all required elements for proper coding and billing.
Orthopedic Evaluation for Supraspinatus Tear
Specialty: OrthopedicsRequired Elements
- Patient history
- Physical examination findings
- Imaging results
- Diagnosis and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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