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

ICD-10 Coding for Rotator Cuff Tear Right Shoulder

M75.121
S46.011A

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

Also Known as:
Right Shoulder Rotator Cuff Injury
Right Shoulder Tendon Tear
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Key Information: ICD-10 Coding for Rotator Cuff Tear Right Shoulder

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

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 confirmation of full-thickness tear
documentation:
  • • Documentation of non-traumatic etiology

Applicable To

  • • Degenerative rotator cuff tear
  • • Atraumatic rotator cuff tear

Important Notes

  • • Ensure documentation specifies the tear as non-traumatic and complete.

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

Billable Code
S46.011A
Billable

Diagnostic Criteria

clinical:
  • • History of trauma or injury
  • • Imaging showing acute tear

Applicable To

  • • Acute traumatic rotator cuff tear

Important Notes

  • • Ensure documentation clearly states the traumatic nature of the tear.
Ancillary Codes

Additional codes that may be used with this diagnosis

M75.51

Bursitis of right shoulder

Use when bursitis is present alongside the rotator cuff tear.

Frequently Asked Questions

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

The ICD-10 code for a complete non-traumatic rotator cuff tear of the right shoulder is M75.121. For traumatic tears, use S46.011A.

How do you document a rotator cuff tear?

Documentation should include laterality, tear type (complete or partial), etiology (traumatic or non-traumatic), and imaging findings.

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