Shoulder lesions — ICD-10 M75.120

ICD-10: M75.120 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions, classified under ICD-10 code M75.120, refer to a variety of injuries or degenerative changes affecting the structures around the shoulder joint, including tendons, ligaments, and cartilage. These lesions can result from acute trauma or chronic overuse, leading to pain, decreased range of motion, and functional impairment. Understanding shoulder lesions is crucial for clinicians as they represent a common cause of musculoskeletal complaints in both active and sedentary populations.

The shoulder joint is one of the most mobile joints in the human body, comprising three main bones: the humerus, scapula, and clavicle. The glenohumeral joint connects the humerus to the scapula, while the acromioclavicular (AC) joint connects the clavicle to the scapula.

Key Structures Involved:

• Rotator Cuff: A group of four muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that stabilize and move the shoulder.
• Labrum: A fibrocartilaginous structure that deepens the glenoid cavity and provides stability.
• Bursa: Fluid-filled sacs that reduce friction between moving structures.

Biomechanics:

The shoulder's wide range of motion allows for various activities but also predisposes it to injuries. The rotator cuff muscles play a vital role in dynamic stabilization during overhead activities. Any disruption in these structures can lead to biomechanical imbalances, resulting in pain and dysfunction.

Patient presents with shoulder pain after lifting heavy boxes at work. Upon examination, the clinician diagnoses a rotator cuff tear. Code as M75.120 because it accurately specifies the diagnosis of a shoulder lesion, indicating a partial tear of the rotator cuff without further specificity, which is appropriate given the patient’s symptoms and history.

To support medical necessity for the ICD-10 code M75.120 and to prevent claim denials, the following documentation elements are crucial:

• Detailed Patient History: Document the patient's history of present illness, including onset, duration, and exacerbating factors of shoulder pain.
• Physical Examination Findings: Include specific results from the physical examination, highlighting any limitations in range of motion or strength, as well as any tenderness or swelling.
• Diagnostic Tests: If applicable, include results from imaging studies (e.g., X-rays, MRIs) that support the diagnosis of a shoulder lesion.
• Treatment Plan: Clearly outline the recommended treatment plan, including referrals to specialists, prescribed therapies, and follow-up appointments.
• Progress Notes: Maintain ongoing documentation of the patient's progress and response to treatment to justify continued medical necessity.

Subjective: A 45-year-old male patient reports persistent pain in his right shoulder for the past six weeks, worsening with overhead activities. He denies any previous shoulder injuries but states he has a physically demanding job as a warehouse worker. Objective: On examination, there is tenderness to palpation over the greater tuberosity of the humerus. Active range of motion is limited, particularly in abduction and external rotation. Strength testing reveals a 4/5 strength in the rotator cuff muscles. Assessment: Right shoulder lesion (M75.120) consistent with a rotator cuff injury secondary to repetitive strain. Plan: Recommend physical therapy for shoulder strengthening and flexibility. Prescribe NSAIDs for pain management. Schedule a follow-up appointment in 4 weeks to assess progress. If symptoms persist, consider an MRI for further evaluation.

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

1. Rotator Cuff Tear (M75.121): Complete or partial tear requiring specific rehabilitation strategies.
2. Shoulder Bursitis (M75.51): Inflammation without significant structural damage.
3. Shoulder Impingement Syndrome (M75.41): Overlapping symptoms but primarily due to mechanical compression.
4. Adhesive Capsulitis (M75.0): Characterized by stiffness rather than structural damage.

Accurate documentation is critical for billing purposes:

Key Elements to Document:

1. Detailed history including onset, duration, and severity of symptoms.
2. Comprehensive physical examination findings including special tests performed.
3. Imaging results supporting diagnosis.
4. Treatment plan including rehabilitation protocols followed.

Billing Guidance:

Use M75.120 for general shoulder lesions but consider additional codes for specific diagnoses such as rotator cuff tears or bursitis if applicable.