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Wondering how others would code this dx: right shoulder rotator cuff partial tear/tendinitis? Would you code both the tear (840.4) as well as tendinitis (726.10) or would you think the doctor isnt sure so just a pain code..? Thank you
If not, the diagnosis for a partial tear of the rotator cuff is 726.13. You can code the shoulder pain, also if it is documented [719.41]. If there are symptoms only for the rotator cuff, I would use 726.10 and the shoulder pain.
This is how I do it, but you may get other opinions.
Looks to me as if the provider is trying to say that the patient has both, but it would have been nice if he/she hadn't used the "/" and had used "and".