Shoulder lesions — ICD-10 M75.1

ICD-10: M75.1 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions, classified under ICD-10 code M75.1, encompass a variety of injuries and conditions affecting the structures of the shoulder joint, including the rotator cuff, labrum, and surrounding soft tissues. These lesions can result from acute trauma or chronic overuse and often lead to pain, reduced range of motion, and functional impairment. Clinically, shoulder lesions are characterized by their impact on daily activities and quality of life, making early diagnosis and appropriate management crucial.

The shoulder joint is a complex structure composed of three primary bones: the humerus, scapula, and clavicle. It is classified as a ball-and-socket joint, allowing for a wide range of motion. Key anatomical components include:

• Rotator Cuff: A group of four muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that stabilize the humeral head within the glenoid cavity.
• Glenoid Labrum: A fibrocartilaginous rim that deepens the glenoid cavity and provides stability to the shoulder joint.
• Bursa: Fluid-filled sacs that reduce friction between moving parts in the shoulder.

Biomechanically, the shoulder relies on a delicate balance of muscular strength and neuromuscular control to maintain stability during dynamic activities such as throwing or lifting. The rotator cuff plays a pivotal role in this stability by centering the humeral head during arm movements.

Patient presents with left shoulder pain after lifting a heavy box. The examination reveals tenderness over the greater tuberosity and limited range of motion. Code as M75.1 because the documentation indicates a specific shoulder lesion characterized by pain and functional impairment, consistent with the ICD-10 description for rotator cuff disorders.

To support medical necessity for coding M75.1 and to prevent claim denials, the following documentation elements are essential:

1. Detailed History: A thorough account of the patient's symptoms, including onset, duration, and impact on daily activities.

1. Physical Examination Findings: Document specific findings related to shoulder functionality, including range of motion limits and tenderness locations.

1. Diagnostic Tests: Include results from imaging studies (e.g., MRI) if performed, to substantiate the diagnosis of a shoulder lesion.

1. Treatment Plan: Clear documentation of the recommended interventions, including referrals for physical therapy and any prescribed medications.

1. Follow-Up: Notes about any follow-up visits to track the progression of the condition and response to treatment.

Subjective: A 45-year-old female presents with a 3-month history of left shoulder pain, which worsens with overhead activities and is accompanied by weakness in her left arm. Objective: On examination, there is notable tenderness over the supraspinatus tendon, and the patient exhibits a positive Neer test. Range of motion is limited in abduction and external rotation. Assessment: The patient has a shoulder lesion, likely a rotator cuff tear, as evidenced by clinical findings and the patient's history. Plan: Order an MRI to confirm the diagnosis, recommend physical therapy focusing on strengthening and flexibility, and prescribe anti-inflammatory medication to manage pain.

When evaluating shoulder lesions, it is crucial to differentiate them from other conditions that may present similarly:

1. Rotator Cuff Tear (M75.121): Full-thickness tear versus partial-thickness tear must be differentiated based on imaging findings.
2. Shoulder Impingement Syndrome (M75.4): Characterized by pain during overhead activities without significant structural damage.
3. Labral Tear (M75.121): Often associated with instability or clicking sensations during movement.
4. Subacromial Bursitis (M75.51): Inflammation of the bursa leading to localized pain but typically without significant weakness.

Accurate documentation is crucial for supporting medical necessity and ensuring appropriate coding for shoulder lesions (ICD-10 M75.1). Here are specific tips to enhance your clinical documentation:

1. Detail Patient History: Include a comprehensive history of present illness (HPI) that describes the onset, duration, and characteristics of shoulder pain, as well as any previous treatments or interventions.

1. Clinical Findings: Document specific physical examination findings, including range of motion, strength testing, and any observed deformities or tenderness in the shoulder region.

1. Imaging and Tests: Include any imaging studies (X-rays, MRI) or diagnostic tests performed, along with the results and how they correlate with the diagnosis of shoulder lesions.

1. Treatment Plan: Clearly outline the treatment options discussed with the patient, including any referrals made, conservative management strategies, or surgical considerations.

1. Functional Impact: Describe how the shoulder lesion has affected the patient’s daily activities and quality of life, which can support the need for specific interventions or therapies.

1. Follow-Up Plan: Document the follow-up plan, including timelines for reassessment, further imaging, or referrals, to demonstrate ongoing management of the condition.