Pain Management Coding Alert

Question: The provider performs a level-three evaluation and management (E/M) service for an established patient with a torn rotator cuff. What is the correct ICD-10 code for a torn rotator cuff?
Ohio Subscriber

Answer: You’ll need to know whether the tear was nontraumatic or traumatic before you can add the correct ICD-10 code to your 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) claim.

Nontraumatic: If the notes do not mention that the cuff tear was traumatic, then you’ll choose from one of the following code sets, depending on encounter specifics:

• M75.10- — Unspecified rotator cuff tear or rupture, not specified as traumatic
• M75.11- — Incomplete rotator cuff tear or rupture not specified as traumatic
• M75.12- — Complete rotator cuff tear or rupture not specified as traumatic.

6th character needed: No matter which of the above diagnosis codes you choose, you’ll need to include a sixth character to indicate laterality.

Traumatic: If notes specify that the tear was traumatic, you’ll choose one of the codes from the S46.01-- (Strain of muscle(s) and tendon(s) of the rotator cuff of shoulder) family instead, depending on encounter specifics.

6th, 7th character needed: For traumatic rotator cuff tears, you’ll need a sixth character to indicate laterality, along with a seventh character to indicate the type of visit.  

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