Radiology Coding Alert

Question: A radiologist’s report indicates a full-thickness tear of the supraspinatus and a partial tear of the infraspinatus, both non-traumatic, for the patient’s rotator cuff. Should you use codes to report both the complete and incomplete rotator cuff tears?

Missouri Subscriber

Answer: Yes, you should report both the complete and partial tears of the patient’s rotator cuff. A complete rotator cuff tear refers to a full tear of the supraspinatus that helps stabilize and/or move the shoulder. Meanwhile, a partial tear is an incomplete rotator cuff tear or a rupture of one of the shoulder’s tendons or muscles — in this case, the infraspinatus.

The radiologist’s report calls out both tears as non-traumatic injuries, so you can use the codes in the M75.1 (Rotator cuff tear or rupture, not specified as traumatic) series. You will use ICD-10-CM codes M75.11- (Incomplete rotator cuff tear or rupture not specified as traumatic) for the partial tear of the infraspinatus. You’ll use codes M75.12- (Complete rotator cuff tear or rupture not specified as traumatic) to document the full-thickness tear of the supraspinatus.

Excludes1 Note: If a tear of the rotator cuff, be it partial or complete, is traumatic, then you cannot report it alongside non-traumatic tears.

Additionally, the M75.11- and M75.12- codes will require a 6th character to designate the right shoulder, left shoulder, or an unspecified shoulder. The ICD-10-CM guidelines also note you will need to use an external cause code, if applicable, after coding the musculoskeletal condition, as this will help identify the cause of the injury.