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

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.

How do you document a traumatic rotator cuff tear?

Document the traumatic event, specify the tendon involved, confirm with imaging, and note laterality to ensure accurate coding.

ICD-10 Coding for Traumatic Rotator Cuff Tear(S46.011A, M75.1, M75.121)

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Learn about the ICD-10 coding for traumatic rotator cuff tears, including documentation requirements and common pitfalls.

Also known as:

Acute Rotator Cuff TearTraumatic Shoulder Tear

Related ICD-10 Code Ranges

Complete code families applicable to Traumatic Rotator Cuff Tear

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 when there is a documented traumatic event leading to a rotator cuff tear in the right shoulder.	Documented trauma such as fall or lifting injury MRI confirmation of full or partial thickness tear Physical exam findings like positive drop arm test
S46.012A	Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter	Use when there is a documented traumatic event leading to a rotator cuff tear in the left shoulder.	Documented trauma such as fall or lifting injury MRI confirmation of full or partial thickness tear Physical exam findings like positive drop arm test

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 traumaticM75.121

Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumaticM75.122

Documentation & Coding Risks

Avoid these common issues when documenting Traumatic Rotator Cuff Tear.

Failing to document laterality

Impact

Clinical: Ambiguity in treatment planning and follow-up., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials or reduced reimbursement.

Mitigation

Always specify right or left shoulder in documentation., Use templates that prompt for laterality.

Using M75.1- for traumatic tears

Impact

Reimbursement: Incorrect coding can lead to denied claims or reduced reimbursement., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data affecting patient records and outcomes.

Mitigation

Use S46.01- with appropriate laterality and external cause codes.

Unspecified Laterality

Impact

Coding without specifying right or left can lead to audit flags.

Mitigation

Ensure all documentation includes laterality.

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 codes9

Coding risks3

FAQs2

ICD-10 Coding for Traumatic Rotator Cuff Tear(S46.011A, M75.1, M75.121)

Documentation & Coding Risks

Frequently Asked Questions

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

How do you document a traumatic rotator cuff tear?

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