Shoulder lesions — ICD-10 M75.111

ICD-10: M75.111 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions, classified under ICD-10 code M75.111, refer to a range of injuries or pathological conditions affecting the shoulder joint and its surrounding structures, including muscles, tendons, and ligaments. These lesions can result from acute trauma, chronic overuse, or degenerative processes. Clinically, shoulder lesions may manifest as pain, limited range of motion, and functional impairment, significantly affecting a patient's quality of life and ability to perform daily activities.

The shoulder joint is one of the most mobile joints in the human body, allowing a wide range of motion. However, this mobility also makes it susceptible to various injuries and conditions that can lead to significant morbidity if not properly diagnosed and managed.

The shoulder complex consists of several key anatomical structures:

• Glenohumeral Joint: The ball-and-socket joint formed by the humeral head and the glenoid cavity of the scapula.
• Rotator Cuff: A group of four muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that stabilize the shoulder joint.
• Scapula: The shoulder blade that provides attachment points for muscles and contributes to shoulder mobility.
• Clavicle: The collarbone that connects the arm to the body and acts as a strut to stabilize the shoulder.
• Labrum: A fibrocartilaginous structure that deepens the glenoid cavity and provides stability.

Biomechanically, the shoulder's extensive range of motion is facilitated by the coordinated action of these structures. The rotator cuff plays a crucial role in stabilizing the humeral head within the shallow glenoid cavity during dynamic movements. Any disruption to these anatomical components can lead to shoulder lesions characterized by pain, weakness, and functional limitations.

Patient presents with a 45-year-old male who reports persistent pain in the right shoulder, particularly when lifting objects above his head. The pain has progressively worsened over the past three months. Upon examination, the physician notes tenderness in the rotator cuff area, and imaging studies reveal a partial tear. Code as M75.111 because the diagnosis is a shoulder lesion classified under the ICD-10-CM guidelines, specifically indicating a rotator cuff tear.

To support medical necessity for ICD-10 code M75.111 and prevent claim denials, healthcare providers must ensure comprehensive documentation that includes:

• A detailed history of present illness outlining the onset, duration, and characteristics of shoulder pain.
• A thorough physical examination with specific findings related to the shoulder, including range of motion and tenderness locations.
• Imaging results that confirm the diagnosis, such as MRI or X-ray reports indicating the presence of a shoulder lesion.
• A clear treatment plan that outlines interventions, such as physical therapy referrals or prescribed medications, demonstrating a plan to manage the diagnosis.

Subjective: A 62-year-old female presents to the clinic with complaints of right shoulder pain that started six weeks ago after lifting a heavy suitcase. She describes the pain as sharp and radiating down the arm, particularly when reaching overhead or behind her back. Objective: Physical examination reveals limited range of motion in the right shoulder, with tenderness noted over the supraspinatus tendon. An MRI confirms a partial thickness tear of the rotator cuff. Assessment: Right shoulder lesion (ICD-10 code M75.111) due to a partial rotator cuff tear, likely related to overexertion injury. Plan: The patient is referred for physical therapy to strengthen the shoulder muscles and improve range of motion. Non-steroidal anti-inflammatory medications are prescribed for pain management, and a follow-up appointment is scheduled in four weeks to assess progress.

When evaluating a patient with suspected shoulder lesions, it is important to consider differential diagnoses:

1. Rotator Cuff Tear (ICD-10 Code M75.121): Characterized by pain and weakness in arm elevation.
2. Shoulder Impingement Syndrome (ICD-10 Code M75.41): Pain during overhead activities due to tendon irritation.
3. Labral Tear (ICD-10 Code M75.121): Pain with specific movements; may present with catching sensations.
4. Frozen Shoulder (Adhesive Capsulitis) (ICD-10 Code M75.0): Progressive stiffness and pain limiting range of motion.
5. Subacromial Bursitis (ICD-10 Code M70.61): Inflammation causing pain during arm elevation.

Differentiating between these conditions is crucial for appropriate management.

Accurate documentation is essential for billing purposes under ICD-10 code M75.111:

1. Document patient history comprehensively, including symptom onset, duration, aggravating/relieving factors, and previous treatments attempted.

1. Include detailed physical examination findings—range of motion assessments, strength testing results, and any positive special tests performed.

1. Imaging results should be documented clearly if they influence treatment decisions.

1. Use relevant modifiers when billing for physical therapy services related to shoulder lesions (e.g., GP modifier indicating services delivered under an outpatient physical therapy plan).

1. Ensure that all documentation aligns with medical necessity criteria to support claims effectively.