ICD-10-CM Billable Code

M75.122

Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic

Clinical Classification Guidelines

Medical Intelligence & Overview

A complete rotator cuff tear of the left shoulder, classified under ICD-10 code M75.122, refers to a complete rupture or tear of the tendons in the rotator cuff group within the shoulder, specifically on the left side. This condition involves the tearing of the tendons without a specific trauma or injury being identified as the cause. The rotator cuff is a crucial component of shoulder stability and movement, and its injury can significantly impair arm function.

Causes & Symptoms

Clinical Causes: Degenerative changes due to aging Repeated overhead activities or motions Chronic shoulder impingement Muscle or tendon degeneration over time Trauma or injury (although in this case, not specified as traumatic)

Key Symptoms: Persistent shoulder pain, particularly at night or when lying on the affected side Weakness in shoulder movements Reduced range of motion Difficulty lifting or rotating the arm A feeling of shoulder instability or clicking

Diagnostic & Treatment

Diagnosis Path: Diagnosis typically involves a detailed physical examination assessing shoulder strength, range of motion, and identification of tender points. Imaging studies like MRI are often used to confirm the extent of the tear, determining whether it is partial or complete, and assessing the overall condition of the rotator cuff tendons.

Treatment Protocols: Management options can vary depending on the severity of the tear and the patient's functional needs. Common treatments include:

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 M75.122 a billable ICD-10 code?
Yes, M75.122 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report M75.122?
Clinical documentation must specify the nature of Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic and any associated comorbidities for accurate reporting.

Cite this Clinical Reference