Complete ICD-10-CM coding and documentation guide for icd-10 coding for traumatic 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 Traumatic 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
Fall from same level, initial encounter
Use to specify the external cause of the traumatic event.
The ICD-10 code for a traumatic rotator cuff tear is S46.01-, with specific codes for laterality such as S46.011A for the right shoulder.
Document the traumatic event, specify the tendon involved, confirm with imaging, and note laterality to ensure accurate coding.