ICD-10-CM Billable Code

M75.101

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

Clinical Classification Guidelines

Medical Intelligence & Overview

A rotator cuff tear involves damage to one or more of the tendons in the shoulder, which can lead to pain, weakness, and limited movement. The specific ICD-10 code M75.101 refers to an unspecified tear or rupture of the rotator cuff in the right shoulder that is not caused by trauma. This condition can develop gradually over time or due to degenerative changes, affecting daily activities and overall shoulder function.

Causes & Symptoms

Clinical Causes: Degenerative changes in the shoulder tendons with age Repetitive shoulder movements, especially overhead activities Chronic shoulder impingement Muscle imbalances or weakness around the shoulder Previous shoulder injuries or overuse

Key Symptoms: Dull or aching pain in the shoulder, especially at night Weakness or decreased strength in the right arm Limited range of motion, particularly in shoulder lifting or reaching Difficulty performing overhead activities Crackling or popping sensations during shoulder movement

Diagnostic & Treatment

Diagnosis Path: Diagnosis typically involves a combination of clinical assessment and imaging tests. A healthcare provider may perform physical exams to assess shoulder strength and identify specific movement limitations. Imaging modalities such as MRI (Magnetic Resonance Imaging) are often used to visualize soft tissue structures and confirm the presence of a rotator cuff tear or rupture, helping to determine its extent and exact location.

Treatment Protocols: Treatment options focus on relieving symptoms and restoring shoulder function. Non-surgical approaches are usually tried first, 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 M75.101 a billable ICD-10 code?
Yes, M75.101 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report M75.101?
Clinical documentation must specify the nature of Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic and any associated comorbidities for accurate reporting.

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