Wiki Rotator Cuff Tear - I have a provider

[jazzyblues2005]

I have a provider that gives the following as a diagnosis:
"Right shoulder rotator cuff tear, massive, supraspinatus and infraspinatus"

I'm debating on just coding 840.4, as it is an acute injury, or whether to code 840.4, 840.6, and 840.3 together.

Any opinions?

Thanks!

 

[dclark7]

The rotator cuff is actually made up of 4 muscles and their tendons; the subscapularis, supraspinatus, infraspinatus and teres minor. You should only use 840.4 if the specific muscle is not documented. Since in this case you have two documented you should use both 840.3 and 840.6