Complete ICD-10-CM coding and documentation guide for icd-10 coding for rotator cuff tear includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Rotator Cuff Tear
Use ICD-10 code S46.011A for strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Other shoulder lesions
Use when bursitis is present with the tear.
Rotator cuff tendinitis
Use if inflammation is documented with the tear.
The ICD-10 code for a traumatic rotator cuff tear is S46.01-, while M75.1- is used for non-traumatic tears.
Acute tears are coded as traumatic (S46.01-) if linked to an injury, while chronic tears are degenerative (M75.1-) with no trauma history.