Anesthesia Coding Alert

You’ll need that extra ‘location’ detail for ICD-10 coding.

When your anesthesiologist is involved in the repair of non-traumatic rotator cuff tears, you’ll need to answer two specific questions beginning in 2014: Which shoulder was involved? Was the tear partial or complete?

Examine What Muscles Constitute the Rotator Cuff

The rotator cuff, formed by 4 muscles (Supraspinatus, infraspinatus, teres minor, and subscapularis), helps to stabilize the shoulder. These muscles arise from the scapula and insert into the humerus, thus forming a cuff around the shoulder joint.

Tears (partial or complete) can be caused by trauma or wear and tear. This leads to pain and restriction of movement at the shoulder joint. Injury to the rotator cuff occurs during motions that involve pulling or repeated overhead movements.

Remember Your ICD-9 Options

When reporting rotator cuff tears, you select between ICD-9 codes 727.61 (Complete rupture of rotator cuff) or 726.13 (Partial tear of rotator cuff). You simply need to know whether the tear was partial or complete to know the appropriate code.

Focus on Extent of Damage for ICD-10

ICD-10 offers you more options for rotator cuff tears, based on the extent of tear and the site of injury. Your choices for complete tears will include:

M75.120 — Complete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic

M75.121 — Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic

M75.122 — Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic

You’ll have similar codes to choose from for partial tears, which are not traumatic in nature:

M75.110 — Incomplete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic

M75.111 — Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic

M75.112 — Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic

Documentation spotlight: The descriptors of these ICD-10 codes indicate the codes are appropriate for tears or ruptures "not specified as traumatic." You report these codes when your surgeon clearly documents that the tear was not caused by trauma. You also turn to these codes when your surgeon provides no documentation to support if the tear was traumatic or non-traumatic in nature.

Tip: If the documentation doesn’t specify complete or partial, you may turn to M75.100 (Unspecified rotator cuff tear or rupture or unspecified shoulder, not specified as traumatic). The corresponding ICD-9 code is 726.10 (Disorders of bursae and tendons in shoulder region unspecified).