ICD-10-CM Billable Code

M75.111

Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic

Clinical Classification Guidelines

Medical Intelligence & Overview

An incomplete rotator cuff tear in the right shoulder refers to a partial injury where the tendons of the rotator cuff are damaged but not fully torn. The rotator cuff is a group of muscles and tendons that stabilize the shoulder and allow for a wide range of motion. This condition can develop gradually or from an injury and is generally characterized by shoulder pain, weakness, and limited mobility. Being aware of this condition can help individuals seek appropriate diagnosis and management to reduce discomfort and improve shoulder function.

Causes & Symptoms

Clinical Causes: Repetitive overhead activities (such as in sports or certain occupations) Degenerative changes due to aging Minor trauma or shoulder strain Poor shoulder biomechanics or muscle imbalances Previous shoulder injuries leading to tendon weakening

Key Symptoms: Dull or aching pain around the shoulder, especially at night Weakness or difficulty lifting or rotating the arm Limited range of motion, with difficulty reaching overhead or behind the back Tenderness or tenderness to touch over the shoulder Mild swelling or discomfort after activity

Diagnostic & Treatment

Diagnosis Path: Diagnosis typically involves a combination of clinical evaluation and imaging studies. A healthcare provider will examine shoulder strength, flexibility, and pain points. Imaging techniques such as ultrasound or magnetic resonance imaging (MRI) are used to visualize the tendons and confirm the presence of an incomplete tear or degeneration of the rotator cuff tendons. These tools help differentiate between partial tears and full ruptures, guiding appropriate treatment options.

Treatment Protocols: Management of an incomplete rotator cuff tear may include various strategies aimed at relieving symptoms and restoring shoulder function. Common approaches include: - Rest and activity modification to prevent further injury - Physical therapy focusing on strengthening shoulder muscles and improving flexibility - Nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce pain and inflammation - Corticosteroid injections in some cases to decrease inflammation - Use of shoulder supports or braces for stabilization In cases where conservative treatments do not alleviate symptoms or if the tear worsens, surgical intervention may be considered. Such procedures aim to repair or debride damaged tendons to restore shoulder integrity and function.

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 M75.111 a billable ICD-10 code?
Yes, M75.111 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report M75.111?
Clinical documentation must specify the nature of Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic and any associated comorbidities for accurate reporting.

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