Radiology Coding Alert

Question: A patient came into our practice complaining of right shoulder pain after shoveling snow on their driveway. Their primary care physician referred them to receive an ultrasound of the shoulder. After performing the ultrasound, the radiologist documents the diagnosis as an incomplete tear of the right rotator cuff due to snow shoveling.

What diagnosis codes should I use to document the visit?

North Dakota Subscriber

Answer: The two codes you’ll use to document the patient’s diagnosis are M75.111 (Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic) and Y93.H1 (Activity, digging, shoveling and raking).

Why? When you look up “Torn” in the Alphabetic Index of the ICD-10-CM code set, you’ll be directed to “Tear”. Under “Tear, torn (traumatic) (see also Laceration),” you’ll discover rotator cuff (nontraumatic) > incomplete, which directs you to M75.11 (Incomplete rotator cuff tear or rupture not specified as traumatic). In the tabular list, M75.11 carries a 6^th character required icon, so you’ll need to assign M75.111 to specify the injury occurred to the right shoulder.

You also indicated the provider documented the patient was shoveling snow when the injury occurred. For the activity, you’ll assign a code from the Y93.H (Activities involving exterior property and land maintenance, building and construction) code family. Code Y93.H1 features an additional synonym, Activity, snow shoveling, which contributed to the patient’s condition.

While the descriptor for parent activity code Y93.2 (Activities involving ice and snow) includes the words “snow” and “ice,” the code features an Excludes1 note that indicates you won’t assign a code for shoveling snow and ice with this code family.  That’s because codes listed in the Y93.2 (Activities involving ice and snow) code family are for recreational activities performed on or around ice and in the snow. These activities include snowboarding, sledding, ice skating, ice hockey, and cross-country skiing.