ICD-10 Coding for Traumatic Rotator Cuff Tear(S46.011A, S46.012A)
Complete ICD-10-CM coding and documentation guide for Traumatic Rotator Cuff Tear. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Traumatic Rotator Cuff Tear
S46.01-Primary Range
Strain of muscles/tendons of rotator cuff
Primary range for coding traumatic rotator cuff tears involving muscles or tendons.
Sprain of rotator cuff capsule
Used for traumatic capsular tears, often associated with dislocations.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S46.011A | Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter | Use when there is a documented traumatic event leading to a rotator cuff tear in the right shoulder. |
|
| S46.012A | Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter | Use when there is a documented traumatic event leading to a rotator cuff tear in the left shoulder. |
|
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 traumatic rotator cuff tear
Essential facts and insights about Traumatic Rotator Cuff Tear
Primary ICD-10-CM Codes for traumatic rotator cuff tear
Decision Criteria
clinical Criteria
- Presence of acute trauma leading to shoulder pain and weakness.
documentation Criteria
- MRI or ultrasound confirmation of tear.
Applicable To
- Acute traumatic tear of right supraspinatus
- Acute traumatic tear of right infraspinatus
Excludes
- Non-traumatic rotator cuff tear (M75.1-)
Clinical Validation Requirements
- Documented trauma such as fall or lifting injury
- MRI confirmation of full or partial thickness tear
- Physical exam findings like positive drop arm test
Code-Specific Risks
- Incorrectly coding as non-traumatic (M75.1-)
- Failing to specify laterality
Coding Notes
- Ensure documentation clearly states the traumatic nature and specifies the tendon involved.
S46.012A - Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter
Use when there is a documented traumatic event leading to a rotator cuff tear in the left shoulder.
Applicable To
- Acute traumatic tear of left supraspinatus
- Acute traumatic tear of left infraspinatus
Excludes
- Non-traumatic rotator cuff tear (M75.1-)
Clinical Validation Requirements
- Documented trauma such as fall or lifting injury
- MRI confirmation of full or partial thickness tear
- Physical exam findings like positive drop arm test
Coding Notes
Ensure documentation clearly states the traumatic nature and specifies the tendon involved.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Fall from same level, initial encounter
W19.XXXADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Traumatic Rotator Cuff Tear to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S46.011A.
Impact
Clinical: Ambiguity in treatment planning and follow-up., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Always specify right or left shoulder in documentation., Use templates that prompt for laterality.
Impact
Reimbursement: Incorrect coding can lead to denied claims or reduced reimbursement., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data affecting patient records and outcomes.
Mitigation Strategy
Use S46.01- with appropriate laterality and external cause codes.
Impact
Coding without specifying right or left can lead to audit flags.
Mitigation Strategy
Ensure all documentation includes laterality.
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 Traumatic Rotator Cuff Tear, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Traumatic Rotator Cuff Tear
Use these documentation templates to ensure complete and accurate documentation for Traumatic Rotator Cuff Tear. These templates include all required elements for proper coding and billing.
Initial Evaluation of Traumatic Rotator Cuff Tear
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Specific tendon(s) involved
- Imaging results
- Physical exam findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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