ICD-10 Code M75.1: Rotator Cuff Tear or Rupture (Non-Traumatic) 2025 Billing updates

The icd 10 code for rotator cuff tendinitis specifically relates to M75.1, which designates "Rotator cuff tear or rupture, not specified as traumatic." Accurate coding of this condition is more crucial than ever, as clinics that implement correct ICD-10 coding practices experience a 25% increase in revenue cycle efficiency and a 30% reduction in coding errors. Furthermore, healthcare facilities utilizing proper laterality codes see 20% fewer claim denials—particularly relevant for rotator cuff injuries that typically affect one side of the body.

The 2025 update of ICD-10 brings enhanced specificity for musculoskeletal conditions, potentially affecting how you code and bill rotator cuff injuries. Additionally, the healthcare system has implemented 50 new ICD-10-PCS codes as of April 1, 2025, indicating ongoing changes in coding practices. Notably, the introduction of detailed laterality options (right, left, bilateral) for joint conditions allows for more precise documentation of rotator cuff pathologies.

This guide explains everything you need to understand about the icd 10 code for right rotator cuff tear and other related codes. We'll examine the specific subcategories, explore the 2025 billing updates, and provide practical guidance to help you avoid common coding errors that lead to claim denials.

What does ICD-10 Code M75.1 represent?

M75.1 serves as the parent code in the ICD-10-CM system representing rotator cuff pathology that develops through degeneration rather than sudden injury. Understanding this code's proper application is crucial for accurate medical billing and appropriate treatment planning for patients with shoulder pain.

How is M75.1 defined in the ICD-10 system?

In the ICD-10 classification system, M75.1 represents "Rotator cuff tear or rupture, not specified as traumatic". This code falls under the broader category of soft tissue disorders as classified by the World Health Organization. It's important to note that M75.1 is a non-billable code, meaning it lacks the specificity required for reimbursement purposes. Therefore, you must select a more detailed subcode from its hierarchy for proper claim submission.

The M75.1 code includes several applicable conditions such as rotator cuff syndrome, supraspinatus tear or rupture not specified as traumatic, and supraspinatus syndrome. This code explicitly excludes traumatic tears of the rotator cuff, which are instead coded under S46.01-.

What conditions fall under this code?

The M75.1 umbrella covers several distinct clinical presentations of non-traumatic rotator cuff pathology. When examining patients with suspected rotator cuff issues, you should look for:

• Shoulder pain localized to the lateral aspect, often worsening with overhead activities
• Weakness or difficulty in shoulder abduction or external rotation
• Positive impingement signs on physical examination (e.g., Neer or Hawkins-Kennedy test)
• Tenderness over the supraspinatus tendon or greater tuberosity

Diagnostic confirmation typically involves imaging evidence from ultrasound or MRI showing partial or full-thickness tears of the rotator cuff tendons. Before assigning this code, you should also exclude other causes of shoulder pain such as adhesive capsulitis, arthritis, or fracture.

What is the difference between traumatic and non-traumatic tears?

The distinction between traumatic and non-traumatic rotator cuff tears is critical for proper coding and subsequent treatment planning. Non-traumatic tears (M75.1) generally develop over time due to wear and tear or various disorders affecting the shoulder. These tears typically occur in the context of age-related degeneration, repetitive microtrauma, or anatomical variations that predispose to tendon damage.

In contrast, traumatic rotator cuff tears result from a specific injury or accident and are coded differently using S46.01- series. The ICD-10 system employs a Type 1 Excludes note with M75.1, explicitly stating that traumatic tears should never be coded simultaneously with non-traumatic tears.

Moreover, the ICD-10 system makes another important distinction with Type 2 Excludes notes for shoulder-hand syndrome (M89.0-), indicating these conditions can occur together but are coded separately. This differentiation ensures proper documentation of the underlying etiology and mechanism of injury.

What are the subcategories under M75.1?

Under the M75.1 classification, several subcategories help pinpoint the exact nature and location of non-traumatic rotator cuff injuries. Understanding these subdivisions is essential for accurate documentation and proper reimbursement.

What is M75.10 and when is it used?

M75.10 represents "Unspecified rotator cuff tear or rupture, not specified as traumatic". This code serves as an intermediate category requiring further specification and is non-billable on its own. You should use M75.10 as a starting point when documentation confirms a non-traumatic rotator cuff tear but lacks details about completeness or laterality.

This category branches into three more specific codes:

• M75.100 (unspecified shoulder)
• M75.101 (right shoulder)
• M75.102 (left shoulder)

Notably, healthcare coding experts advise against using unspecified codes whenever possible to reduce denial risks.

How does M75.101 differ from M75.102?

The key distinction between M75.101 and M75.102 is simply laterality. M75.101 specifically denotes "Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic", while M75.102 indicates the same condition in the left shoulder.

Both codes share identical clinical applications except for the affected side. Proper documentation of laterality is crucial as facilities correctly using laterality codes experience 20% fewer claim denials.

What do M75.11 and M75.12 indicate?

M75.11 signifies "Incomplete rotator cuff tear or rupture not specified as traumatic". This classification applies when imaging shows partial-thickness tearing but the tendon maintains some structural integrity.

Conversely, M75.12 represents "Complete rotator cuff tear or rupture not specified as traumatic", indicating full-thickness tears where the tendon is entirely disrupted.

Both categories further subdivide based on laterality:

• M75.110/111/112 for incomplete tears (unspecified/right/left)
• M75.120/121/122 for complete tears (unspecified/right/left)

When should you use unspecified vs. complete or incomplete tear codes?

You should use unspecified codes (M75.10x) only when clinical documentation lacks clarity about tear completeness. According to coding experts, "in order to decrease the chances of auditors denying your report, avoid [unspecified codes] at all costs".

Complete tear codes (M75.12x) apply when imaging confirms full-thickness disruption of the tendon. Meanwhile, incomplete tear codes (M75.11x) are appropriate for partial-thickness tears where some tendon integrity remains.

Essentially, the specificity hierarchy moves from unspecified (least preferred) to incomplete or complete (most preferred) based on clinical documentation.

What billing updates apply to M75.1 in 2025?

For healthcare providers billing rotator cuff conditions, the 2025 updates to M75.1 coding bring several important changes that affect reimbursement and documentation requirements. Understanding these modifications is essential for preventing claim denials and ensuring proper payment.

Are there any changes in code descriptors or structure?

The 2025 edition of ICD-10-CM M75.1 became effective on October 1, 2024. First of all, it's crucial to remember that M75.1 remains a non-billable/non-specific code that should not be used for reimbursement purposes, as there are multiple subcodes below it containing greater detail. The official long descriptor "Rotator cuff tear or rupture, not specified as traumatic" continues to exclude traumatic rotator cuff tears (S46.01-). Although no structural changes occurred to the M75.1 family in 2025, proper code selection from the specific subcategories remains vital for claim acceptance.

How do the 2025 updates affect reimbursement?

The 2025 updates place M75.120 and related codes within Diagnostic Related Group(s) (MS-DRG v42.0): 557 (Tendonitis, myositis and bursitis with MCC) and 558 (Tendonitis, myositis and bursitis without MCC). Subsequently, Medicare has implemented the multiple procedure payment reduction (MPPR) at 50% for second and subsequent therapy services provided to a patient on the same day. The service with the highest PE relative value unit is paid at 100% while remaining services are paid at 50%.

What documentation is now required for accurate billing?

Accurate documentation for rotator cuff tear billing in 2025 must include:

• Certified plans of care
• Progress reports submitted every 10 treatment visits or 30 days
• Daily notes reflecting treatment minutes, codes used, and patient response

Indeed, Medicare continues to tighten regulations around therapy services, making thorough documentation increasingly important for claim approval.

How do these updates impact outpatient physical therapy billing?

In 2025, the annual therapy threshold remains around $2,410 for PT and SLP services combined. Claims exceeding this amount require the KX modifier as confirmation that services are medically necessary. Additionally, CMS finalized regulatory changes allowing general supervision of physical therapist assistants by physical therapists in private practice for all applicable therapy services. This change acknowledges state licensure protections while reducing administrative burden. The targeted medical review threshold remains at $3,000 for PT and SLP services, with services furnished by PTAs subject to an 85% payment rate when billed with the CQ modifier.

How do you avoid common coding errors with M75.1?

Avoiding coding errors with the ICD-10 code for rotator cuff tendinitis (M75.1) requires attention to detail and proper documentation. Many providers struggle with this specific code family, resulting in denied claims and delayed reimbursements.

What are the most frequent mistakes with rotator cuff coding?

Firstly, using unspecified codes such as M75.10 when more specific options exist leads to frequent claim rejections. In fact, claims with unspecified codes are 25% more likely to be denied by CMS. Another common error involves incorrectly differentiating between traumatic and non-traumatic tears. Remember that traumatic rotator cuff injuries belong to the S46.0- code family, whereas M75.1 codes are exclusively for non-traumatic conditions.

Providers frequently make the mistake of coding both rotator cuff syndrome (M75.1) and impingement syndrome (M75.4) simultaneously, despite these being mutually exclusive under Excludes 1 notes. This violation of ICD-10 guidelines can trigger automatic claim rejections.

How can you ensure correct laterality coding?

Proper laterality documentation is essential since facilities correctly using laterality codes experience 20% fewer claim denials. Always document which shoulder is affected in your examination notes and use templates that specifically prompt for laterality. For right-sided tears, use M75.101, M75.111, or M75.121 depending on tear severity. Left-sided tears should be coded with M75.102, M75.112, or M75.122 respectively.

When should you use additional codes for pain or functional status?

If the diagnosis includes shoulder pain alongside structural pathology, consider whether the pain represents a separate clinical entity. However, if pain is merely symptomatic of the rotator cuff condition, additional coding may create redundancy. Importantly, if your patient has overlapping conditions, verify whether they fall under Excludes 1 (never code together) or Excludes 2 (can be coded together) categories.

What tools can help reduce claim denials?

Regular internal audits can help identify recurring coding patterns and reduce claim rejections by 20%. Electronic systems with built-in ICD-10 guidance can prevent common errors through automated validation. Clinics using automated billing systems saw a 30% reduction in coding errors. Documentation templates specifically designed for shoulder pathologies can ensure all required elements are captured during evaluation. Finally, staying current with coding updates through continuing education prevents using outdated coding practices.

Conclusion

What should you remember about M75.1 coding?

Proper understanding and application of the M75.1 code family remains essential for healthcare providers treating rotator cuff pathologies. Throughout this guide, we've examined how this code specifically represents non-traumatic tears, distinguishing them from traumatic injuries that fall under the S46.01- classification. Additionally, we've explored the critical subcategories that provide necessary specificity for billing purposes.

Remember that M75.1 itself serves as a non-billable parent code. Therefore, you must select appropriate subcodes based on laterality (right, left, or unspecified) and tear completeness (complete, incomplete, or unspecified). Healthcare facilities implementing precise laterality coding experience 20% fewer claim denials, highlighting the financial importance of coding accuracy.

The 2025 updates bring significant changes to reimbursement structures, particularly regarding therapy thresholds and supervision requirements. Consequently, your documentation must now include certified plans of care, regular progress reports, and detailed daily notes to ensure claim approval.

Above all, avoiding common coding errors requires attention to specificity, proper distinction between traumatic and non-traumatic conditions, and correct application of laterality. Regular internal audits and utilizing electronic systems with built-in ICD-10 guidance can drastically reduce coding errors and improve your practice's revenue cycle efficiency.

FAQs

Q1. What is the ICD-10 code for a non-traumatic rotator cuff tear?

The ICD-10 code M75.1 represents "Rotator cuff tear or rupture, not specified as traumatic." However, this is a parent code and more specific subcodes should be used for billing purposes.

Q2. How does M75.101 differ from other rotator cuff tear codes?

M75.101 specifically indicates an unspecified rotator cuff tear or rupture of the right shoulder that is not specified as traumatic. It differs from other codes in terms of laterality and specificity of the tear.

Q3. What documentation is required for accurate billing of rotator cuff tears in 2025?

For accurate billing in 2025, providers must include certified plans of care, progress reports every 10 treatment visits or 30 days, and daily notes detailing treatment minutes, codes used, and patient response.

Q4. How can healthcare providers avoid common coding errors with rotator cuff tears?

To avoid coding errors, providers should use specific codes instead of unspecified ones, correctly differentiate between traumatic and non-traumatic tears, ensure proper laterality coding, and utilize electronic systems with built-in ICD-10 guidance.

Q5. What are the reimbursement implications of the 2025 updates for rotator cuff tear coding?

The 2025 updates affect reimbursement through changes in Diagnostic Related Groups, implementation of multiple procedure payment reduction, and maintenance of annual therapy thresholds. Claims exceeding certain amounts require specific modifiers and may be subject to targeted medical review.

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