ICD-10-CM Billable Code

M71.312

Other bursal cyst, left shoulder

Clinical Classification Guidelines

Medical Intelligence & Overview

A bursal cyst in the shoulder, particularly on the left side, is a fluid-filled sac that forms in the bursa, a small fluid-filled sac that reduces friction between tissues of the body. These cysts can cause discomfort and restrict movement. While they are generally benign, understanding their nature helps in recognizing symptoms and seeking appropriate care.

Causes & Symptoms

Clinical Causes: Repetitive shoulder movements or overuse, leading to increased stress on the bursa Shoulder injuries or trauma that cause inflammation and fluid accumulation Degenerative conditions such as rotator cuff tendinitis or arthritis Poor biomechanics or postural issues contributing to shoulder strain Infections or other inflammatory conditions affecting the shoulder area

Key Symptoms: Localized swelling or palpable lump on the shoulder Pain or tenderness in the shoulder, especially with movement Limited range of motion due to discomfort or mechanical obstruction A sensation of fullness or pressure in the shoulder region Possible redness or warmth if inflammation or infection is present

Diagnostic & Treatment

Diagnosis Path: Diagnosing a bursal cyst involves a physical examination by a healthcare provider, who may assess shoulder movement and check for swelling. Imaging tests such as ultrasound or magnetic resonance imaging (MRI) are commonly used to confirm the presence of a cyst, determine its size, and rule out other conditions. Sometimes, fluid aspiration might be performed to analyze the cyst's contents or relieve symptoms.

Treatment Protocols: Rest and activity modification to reduce shoulder strain Application of ice packs to decrease swelling and alleviate pain Nonsteroidal anti-inflammatory drugs (NSAIDs) to manage inflammation and discomfort Physical therapy aimed at strengthening shoulder muscles and improving flexibility Corticosteroid injections to reduce inflammation within the cyst or bursa Drainage or aspiration of the cyst if it causes significant symptoms or does not resolve spontaneously Surgical intervention in rare cases, such as cyst removal if other treatments fail or if the cyst recurs frequently

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 M71.312 a billable ICD-10 code?
Yes, M71.312 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report M71.312?
Clinical documentation must specify the nature of Other bursal cyst, left shoulder and any associated comorbidities for accurate reporting.

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