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Home/Diagnosis/ICD-10 Coding for Supraspinatus Tear

ICD-10 Coding for Supraspinatus Tear

M75.121
S46.011A

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

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

Essential facts and insights about ICD-10 Coding for Supraspinatus 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:
  • • Confirmed full-thickness tear on imaging
documentation:
  • • Documentation of atraumatic onset

Applicable To

  • • Full-thickness supraspinatus tear

Important Notes

  • • Ensure documentation specifies 'atraumatic' and 'complete tear'.

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 mechanism of injury
  • • Acute pain onset following trauma

Applicable To

  • • Traumatic supraspinatus tear

Important Notes

  • • Ensure documentation includes details of the traumatic event.
Ancillary Codes

Additional codes that may be used with this diagnosis

M25.511

Pain in right shoulder

Use to document associated shoulder pain.

Frequently Asked Questions

What is the ICD-10 code for a supraspinatus tear?

The ICD-10 code for a non-traumatic complete supraspinatus tear is M75.121, while a traumatic tear is coded as S46.011A.

How do you document a supraspinatus tear?

Document the tear's thickness, location, and whether it is traumatic or atraumatic, supported by imaging findings.

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