Home Health ICD-9/ICD-10 Alert

Question: We have a patient who had a rotator cuff repair. He will be receiving nursing and physical therapy. We don't know whether the rotator cuff tear was traumatic; the patient thinks it was just wear and tear from many years. The nurse will take care of the incision site.

I can't find a code for the orthopedic aftercare that would apply to this situation. Code V58.43 (Aftercare following surgery for injury and trauma) is appropriate for conditions classifiable to 800-999, but I don't feel comfortable listing this since we don't know if the injury was due to a trauma.

California Subscriber

Answer: Code for a degenerative rotator cuff tear with 726.10 (Rotator cuff syndrome of shoulder and allied disorders; disorders of bursae and tendons in shoulder region, unspecified).

For a nontraumatic complete rupture of the rotator cuff, list 727.61 (Rupture of tendon, nontraumatic; complete rupture of rotator cuff). Because your patient mentioned "wear and tear," a degenerative rotator cuff tear is most likely the correct diagnosis.

Use V58.78 (Aftercare following surgery of the musculoskeletal system, NEC) to report the aftercare provided in either case. You may also add V58.3 (Attention to surgical dressings and sutures) if you will be providing dressing changes.

Unless otherwise indicated, reader questions were answered by Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.