ICD-10-CM Billable Code

M65.011

Abscess of tendon sheath, right shoulder

Clinical Classification Guidelines

Medical Intelligence & Overview

An abscess of the tendon sheath in the right shoulder is a localized infection that involves a pocket of pus forming within the tendon sheath. The tendon sheath is a protective covering that surrounds tendons, facilitating smooth movement. When infected, it can cause pain, swelling, and impaired shoulder movement. This condition requires prompt medical attention to prevent complications and promote recovery.

Causes & Symptoms

Clinical Causes: Bacterial infections, commonly caused by Staphylococcus aureus or other bacteria entering through a cut, wound, or during surgical procedures. Spread of infection from neighboring tissues or skin infections. Repeated trauma or overuse injuries that compromise tissue integrity, allowing bacteria to invade. Pre-existing medical conditions such as diabetes or immune system suppression that increase infection susceptibility.

Key Symptoms: Severe pain in the right shoulder, which may worsen with movement. Swelling and tenderness around the shoulder joint. Limited range of motion, often due to pain and swelling. Warmth and redness over the affected area. Possible fever or chills if the infection becomes systemic. A palpable lump or mass may be felt in some cases.

Diagnostic & Treatment

Diagnosis Path: Healthcare providers perform a thorough physical examination and review medical history. Diagnostic steps may include:

Treatment Protocols: Managing an abscess of the tendon sheath generally involves a combination of medical approaches, including:

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is M65.011 a billable ICD-10 code?
Yes, M65.011 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report M65.011?
Clinical documentation must specify the nature of Abscess of tendon sheath, right shoulder and any associated comorbidities for accurate reporting.

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