Shoulder lesions — ICD-10 M75.102

ICD-10: M75.102 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions encompass a variety of injuries affecting the structures within the shoulder joint, including tendons, ligaments, cartilage, and bones. The ICD-10 code M75.102 specifically refers to lesions of the shoulder that are not specified as traumatic in nature. These injuries can lead to significant pain, functional impairment, and decreased quality of life if not properly addressed.

Shoulder lesions can arise from various etiologies, including degenerative changes, overuse injuries, and acute trauma. Clinicians must accurately identify and differentiate these lesions to implement effective treatment strategies.

The shoulder is a complex joint comprised of several key anatomical components:

• Glenohumeral Joint: This ball-and-socket joint allows for a wide range of motion in multiple planes.
• Rotator Cuff: Comprised of four muscles (supraspinatus, infraspinatus, teres minor, subscapularis), the rotator cuff stabilizes the glenohumeral joint during movement.
• Biceps Tendon: The long head of the biceps tendon attaches to the superior labrum and plays a role in shoulder stability and movement.
• Labrum: A fibrocartilaginous structure that deepens the glenoid cavity and provides additional stability.

Biomechanically, the shoulder relies on coordinated muscle activity to maintain stability while allowing for extensive mobility. The rotator cuff muscles work synergistically to stabilize the humeral head within the glenoid cavity during arm movements. Disruptions in this balance can lead to lesions and subsequent dysfunction.

Patient presents with persistent left shoulder pain, limited range of motion, and tenderness upon palpation. Imaging reveals a partial thickness tear of the rotator cuff. Code as M75.102 because the diagnosis is specific to a shoulder lesion, indicating a partial rotator cuff tear without further complications, which aligns with the clinical findings and imaging results.

Key documentation elements required to support medical necessity for the ICD-10 code M75.102 include:

1. A clear and thorough patient history detailing the onset and nature of shoulder pain.
2. Specific findings from physical examinations, including range of motion tests and tenderness locations.
3. Imaging results, such as MRI or ultrasound reports, confirming the presence of a shoulder lesion.
4. Documented treatment plans that justify the choice of conservative management, such as physical therapy and medication.
5. Progress notes that reflect ongoing assessments and any adjustments in treatment based on patient response.

Subjective: A 55-year-old female patient reports a 3-month history of left shoulder pain that worsens with overhead activities. She describes the pain as sharp and radiating down her arm, particularly after gardening or lifting objects. She has no prior history of shoulder injuries. Objective: On examination, there is tenderness over the greater tuberosity of the humerus, and the patient demonstrates a limited range of motion in abduction and external rotation. An MRI shows a partial tear in the supraspinatus tendon. Assessment: Left shoulder partial rotator cuff tear (ICD-10 Code M75.102) due to repetitive overhead activities. Plan: The patient is advised to engage in physical therapy focusing on strengthening and range of motion exercises. Nonsteroidal anti-inflammatory drugs (NSAIDs) will be prescribed for pain management. Follow-up in 6 weeks to assess progress.

Differential diagnoses for shoulder lesions include:

1. Rotator Cuff Tear (M75.101): Differentiate from tendinopathy by assessing for full-thickness tears via imaging.
2. Shoulder Impingement Syndrome (M75.4): Characterized by pain during abduction and internal rotation.
3. Biceps Tendon Rupture (M75.12): Presents with a "pop" sensation followed by pain in the anterior shoulder.
4. Adhesive Capsulitis (Frozen Shoulder) (M75.0): Limited range of motion with no history of trauma; often occurs in diabetics.

Accurate diagnosis is critical to avoid mismanagement.

For accurate billing under ICD-10 code M75.102, documentation should include:

1. Detailed patient history including onset, duration, and mechanism of injury.
2. Comprehensive physical examination findings.
3. Results from imaging studies supporting the diagnosis.
4. A clear treatment plan outlining rehabilitation phases and progress notes.

Proper documentation ensures compliance with insurance requirements and facilitates reimbursement.