Shoulder lesions — ICD-10 M75.101

ICD-10: M75.101 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions encompass a range of injuries and disorders affecting the structures of the shoulder joint, including tendons, ligaments, cartilage, and bone. The ICD-10 code M75.101 specifically refers to unspecified shoulder lesions, which can arise from acute injuries, chronic overuse, or degenerative changes. These lesions may result in pain, limited range of motion, and functional impairment, significantly impacting an individual's quality of life.

Understanding shoulder lesions is crucial for clinicians and rehabilitation providers, as proper diagnosis and management are essential for effective recovery. This article will provide an in-depth analysis of shoulder lesions, including their anatomy, pathophysiology, clinical presentation, diagnostic approaches, treatment protocols, and documentation guidance.

The shoulder is a complex joint composed of three primary bones: the humerus (upper arm bone), the scapula (shoulder blade), and the clavicle (collarbone). It is surrounded by various soft tissues, including muscles, tendons, ligaments, and bursae that contribute to its stability and mobility.

Key Anatomical Structures:

• Rotator Cuff: A group of four muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that stabilize the shoulder joint and facilitate movement.
• Glenoid Labrum: A fibrocartilaginous rim that deepens the socket of the shoulder joint, providing additional stability.
• Bursa: Fluid-filled sacs that reduce friction between moving parts in the shoulder.
• Ligaments: Connective tissues that stabilize the joint by connecting bones to other bones.

Biomechanics:

The shoulder joint exhibits a wide range of motion due to its ball-and-socket structure. However, this mobility comes at the cost of stability. The rotator cuff muscles play a vital role in maintaining joint integrity during dynamic movements. Any disruption or injury to these structures can lead to shoulder lesions characterized by pain and dysfunction.

Patient presents with persistent right shoulder pain following a recent fall. Upon examination, a partial tear of the rotator cuff is diagnosed with associated lesions. Code as M75.101 because it accurately reflects the presence of a shoulder lesion in the right shoulder, as per ICD-10-CM guidelines.

To support medical necessity and prevent claim denials for ICD-10 code M75.101, the following documentation elements are critical:

• Detailed History: Document the patient's history of present illness, including onset, duration, and characteristics of symptoms related to shoulder lesions.
• Physical Examination Findings: Clearly outline examination results, including any positive tests indicative of shoulder lesions, such as pain on palpation or range of motion limitations.
• Diagnostic Imaging: Include results from any imaging studies (e.g., MRI or ultrasound) that confirm the presence of shoulder lesions.
• Treatment Plan: Provide a comprehensive plan that includes therapeutic interventions, referrals to specialists, or additional diagnostic tests if necessary.
• Follow-Up Notes: Document follow-up visits and responses to treatment, illustrating continuity of care and the ongoing assessment of the shoulder condition.

Subjective: A 45-year-old male presents with a two-month history of right shoulder pain that worsens with overhead activities. He reports difficulty sleeping due to pain and a sensation of weakness in the shoulder. Objective: On examination, there is tenderness over the greater tuberosity of the humerus. Range of motion is limited, especially during abduction and external rotation. Positive Neer and Hawkins-Kennedy tests indicate potential impingement. Assessment: Right shoulder lesion, likely related to a partial rotator cuff tear, consistent with ICD-10 code M75.101. Plan: Recommend physical therapy focusing on strengthening and flexibility exercises. Prescribe NSAIDs for pain management. Follow-up in 6 weeks to reassess symptoms and progress.

When diagnosing shoulder lesions, it is important to consider other conditions that may present similarly:

1. Rotator Cuff Tear (M75.101) - Partial or complete tear of one or more rotator cuff tendons.
2. Shoulder Bursitis (M75.50) - Inflammation of the bursa leading to pain and limited motion.
3. Frozen Shoulder (Adhesive Capsulitis) (M75.0) - Characterized by stiffness and pain due to inflammation of the shoulder capsule.
4. Glenoid Labrum Tear (S43.42) - Injury to the labrum causing instability and pain.
5. Shoulder Osteoarthritis (M19.91) - Degenerative joint disease leading to pain and reduced function.

Accurate documentation is crucial for billing purposes:

Key Elements for Documentation:

1. Detailed patient history including mechanism of injury.
2. Comprehensive physical examination findings.
3. Results from imaging studies.
4. Treatment plan including rehabilitation protocols.

Billing Guidance:

Ensure that documentation supports the diagnosis coded as M75.101 for unspecified shoulder lesions while considering additional codes for any associated conditions identified during evaluation.