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

The ICD-10 code for a traumatic rotator cuff tear of the right shoulder is S46.011A. Ensure documentation specifies the traumatic nature of the tear.

How do you code a chronic rotator cuff tear?

For a chronic rotator cuff tear of the right shoulder, use ICD-10 code M75.111. Documentation should reflect the degenerative nature and absence of trauma.

ICD-10 Coding for Rotator Cuff Repair(S46.011A, M75.111, M75.1)

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Learn about the ICD-10 coding and documentation requirements for rotator cuff repairs, including traumatic and chronic tears. Ensure accurate billing and compliance.

Also known as:

Shoulder Tendon RepairSupraspinatus Repair

Related ICD-10 Code Ranges

Complete code families applicable to Rotator Cuff Repair

S00-T88Primary Range

Injury, poisoning and certain other consequences of external causes

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Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

Code	Description	When to Use	Key Documentation
S46.011A	Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter	Use for acute traumatic tears of the right rotator cuff.	Documented mechanism of injury Imaging confirming acute tear
M75.111	Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic	Use for chronic degenerative tears of the right rotator cuff.	Chronic shoulder pain history Imaging showing degenerative changes

Primary ICD-10-CM Codes

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

S46.011ABillable

Differential Codes

Alternative codes to consider when ruling out similar conditions

Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumaticM75.111

Use when the tear is degenerative rather than traumatic.

Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounterS46.011A

Use when the tear is due to a specific traumatic event.

Documentation & Coding Risks

Avoid these common issues when documenting Rotator Cuff Repair.

Not specifying acute or chronic for open repairs

Impact

Clinical: Inaccurate clinical records, Regulatory: Potential for audit discrepancies, Financial: Denied claims or incorrect reimbursement

Mitigation

Use templates that prompt for tear chronicity, Educate staff on documentation requirements

Assuming chronicity based on symptom duration

Impact

Reimbursement: Incorrect coding can lead to denied claims., Compliance: May result in audits if documentation does not support the code., Data Quality: Affects the accuracy of clinical data and patient records.

Mitigation

Base chronicity on the presence of trauma, not time since injury.

Laterality

Impact

Missing laterality in documentation can lead to claim denials.

Mitigation

Implement mandatory fields for laterality in EHR templates.

Frequently Asked Questions

Documentation requirements, coding pitfalls and FAQs for conditions coded with S46.011A.

Primary Code

S46.011A

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

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ICD-10 codes6

Coding risks3

FAQs2

ICD-10 Coding for Rotator Cuff Repair(S46.011A, M75.111, M75.1)

Documentation & Coding Risks

Frequently Asked Questions

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

How do you code a chronic rotator cuff tear?

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