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Home/Diagnosis/ICD-10 Coding for Right Rotator Cuff Tear

ICD-10 Coding for Right Rotator Cuff Tear

M75.121
S46.011A

Complete ICD-10-CM coding and documentation guide for icd-10 coding for right rotator cuff tear includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Right Shoulder Rotator Cuff Tear
Right Rotator Cuff Injury
rotator cuff injury right
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Key Information: ICD-10 Coding for Right Rotator Cuff Tear

Essential facts and insights about ICD-10 Coding for Right Rotator Cuff Tear

Use ICD-10 code M75.121 for complete rotator cuff tear or rupture of right shoulder, not specified as traumatic, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic

Billable Code
M75.121
Billable

Diagnostic Criteria

clinical:
  • • MRI shows full-thickness tear
documentation:
  • • No history of recent trauma

Applicable To

  • • Chronic rotator cuff tear
  • • Degenerative rotator cuff tear

Important Notes

  • • Ensure documentation specifies non-traumatic etiology.

Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter

Billable Code
S46.011A
Billable

Diagnostic Criteria

clinical:
  • • Documented traumatic event
  • • Acute onset of symptoms

Applicable To

  • • Acute traumatic tear

Important Notes

  • • Ensure trauma is documented in the patient's history.
Ancillary Codes

Additional codes that may be used with this diagnosis

M75.41

Impingement syndrome of right shoulder

Use when impingement is present alongside the tear.

M25.511

Pain in right shoulder

Use to document associated shoulder pain.

Z47.89

Encounter for other orthopedic aftercare

Use for follow-up care post-surgery.

Frequently Asked Questions

What is the ICD-10 code for a right rotator cuff tear?

The ICD-10 code for a complete non-traumatic right rotator cuff tear is M75.121, while S46.011A is used for traumatic tears.

How do you code a traumatic right rotator cuff tear?

For a traumatic right rotator cuff tear, use ICD-10 code S46.011A, ensuring documentation of the traumatic event.

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