Shoulder lesions — ICD-10 M75.110

ICD-10: M75.110 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions represent a diverse group of injuries and pathologies affecting the structures of the shoulder joint, including muscles, tendons, ligaments, and cartilage. The ICD-10 code M75.110 specifically refers to a lesion of the shoulder region that is not specified as a rotator cuff tear or other specific shoulder conditions. This category encompasses various conditions such as impingement syndrome, tendinopathy, bursitis, and labral tears, which can lead to significant pain, functional limitations, and decreased quality of life.

The shoulder joint is unique due to its complex anatomy and biomechanics, allowing for a wide range of motion but also making it susceptible to injury. Understanding the underlying mechanisms and presentations of shoulder lesions is crucial for accurate diagnosis and effective treatment.

The shoulder joint is a ball-and-socket joint primarily composed of three bones: the humerus (upper arm), scapula (shoulder blade), and clavicle (collarbone). Key anatomical components include:

• Glenohumeral Joint: The articulation between the head of the humerus and the glenoid cavity of the scapula.
• Rotator Cuff: A group of four muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that stabilize the shoulder and facilitate movement.
• Bursa: Fluid-filled sacs that reduce friction between moving structures in the shoulder.
• Labrum: A fibrocartilaginous rim that deepens the glenoid cavity, providing stability.

Biomechanically, the shoulder is designed for mobility rather than stability. This allows for overhead activities and reaching motions but also increases vulnerability to injuries. The rotator cuff plays a pivotal role in maintaining joint stability during dynamic movements, while the bursa serves as a cushion against friction.

Patient presents with persistent pain in the right shoulder following a fall while playing basketball. Upon examination, the physician notes restricted range of motion and tenderness in the anterior shoulder area. Code as M75.110 because the diagnosis is a shoulder lesion due to trauma, which aligns with the clinical findings and the specific criteria for this code in the ICD-10-CM guidelines.

To support medical necessity for ICD-10 code M75.110 and prevent claim denials, key documentation elements include:

• Detailed Patient History: Comprehensive documentation of the patient’s symptoms, duration, and any previous shoulder injuries or treatments.
• Clear Clinical Findings: Objective evidence of physical examination results, including range of motion assessments and specific tests performed to diagnose shoulder lesions.
• Imaging Reports: Include any imaging studies (e.g., MRI, X-ray) that support the diagnosis of a shoulder lesion. Ensure that reports detail the findings relevant to the condition being treated.
• Treatment Plan Documentation: Clearly outline the proposed treatment plan, including physical therapy recommendations, medications, and follow-up care, demonstrating that the condition is being actively managed.
• Rationale for Diagnosis: Provide clear reasoning for the chosen diagnosis code, ensuring it accurately reflects the patient's condition as documented in the medical record.

Subjective: A 52-year-old female patient reports a 3-month history of right shoulder pain, exacerbated by overhead activities such as reaching for items on a shelf. She describes the pain as sharp and radiating down her arm, especially during movement. Objective: Physical examination reveals tenderness over the greater tuberosity of the humerus and a positive Neer test. The patient has limited range of motion in abduction and external rotation. MRI findings indicate a partial thickness tear of the rotator cuff. Assessment: Right shoulder lesion, coded as M75.110, attributed to a partial tear of the rotator cuff due to overuse. Plan: Initiate a physical therapy program focusing on strengthening and range of motion exercises. Consider corticosteroid injections if symptoms do not improve in 4 weeks. Schedule a follow-up appointment in 6 weeks to reassess.

When evaluating a patient with suspected shoulder lesions, it is important to consider differential diagnoses that may present with similar symptoms:

1. Rotator Cuff Tear (M75.121) - Complete or partial tear of one or more rotator cuff tendons.
2. Shoulder Impingement Syndrome (M75.111) - Compression of rotator cuff tendons beneath the acromion during arm elevation.
3. Shoulder Bursitis (M75.51) - Inflammation of the subacromial bursa leading to pain and limited motion.
4. Labral Tear (M75.120) - Injury to the glenoid labrum affecting stability and function.
5. Adhesive Capsulitis (M75.0) - Also known as frozen shoulder; characterized by stiffness and pain.

Accurate differentiation among these conditions is vital for appropriate management.

Proper documentation is essential for accurate billing under ICD-10 code M75.110:

Key Documentation Elements:

1. Detailed patient history including symptom onset, duration, aggravating factors.
2. Comprehensive physical examination findings including range of motion assessments and strength testing results.
3. Imaging results supporting diagnosis if applicable.
4. Treatment plan outlining interventions provided during each phase of rehabilitation.

Billing Guidance:

Ensure all documentation aligns with coding guidelines to support claims submission effectively. Use modifiers where necessary to indicate specific circumstances affecting treatment delivery.