Shoulder lesions — ICD-10 M75.122

ICD-10: M75.122 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions represent a diverse group of injuries affecting the structures of the shoulder joint, including tendons, ligaments, and cartilage. These lesions can result from acute trauma or chronic overuse and may lead to significant functional impairment and pain. The ICD-10 code M75.122 specifically refers to "shoulder lesions, left shoulder," indicating a localized condition that requires targeted assessment and management. Understanding the underlying anatomy, biomechanics, pathophysiology, and treatment options is crucial for effective rehabilitation and recovery.

The shoulder complex consists of several key anatomical structures:

• Glenohumeral Joint: This ball-and-socket joint allows for a wide range of motion, making it one of the most mobile joints in the body.
• Rotator Cuff: Comprising four muscles (supraspinatus, infraspinatus, teres minor, subscapularis), the rotator cuff stabilizes the humeral head within the glenoid cavity during arm movements.
• Labrum: A fibrocartilaginous structure that deepens the glenoid cavity, providing additional stability to the shoulder joint.
• Bursa: Fluid-filled sacs that reduce friction between moving structures in the shoulder.

Biomechanically, the shoulder is designed for mobility but is inherently unstable due to its anatomical configuration. This instability can predispose individuals to injuries such as tears, impingements, or lesions resulting from repetitive overhead activities or acute trauma.

Patient presents with a 45-year-old male who reports persistent pain in the left shoulder, exacerbated by lifting and overhead activities. Upon examination, the physician notes localized tenderness and limited range of motion. Code as M75.122 because the documentation indicates a lesion of the rotator cuff in the left shoulder, which aligns with the specified criteria for this ICD-10 code.

To support medical necessity and prevent claim denials for code M75.122, the following key documentation elements are required:

1. Detailed Clinical History: A thorough history that includes the onset, duration, and characteristics of shoulder pain.
2. Physical Examination Findings: Clearly document physical exam findings, including range of motion, tenderness, and functional limitations.
3. Diagnostic Imaging Results: If applicable, include results from imaging studies (e.g., MRI) that confirm the presence of a rotator cuff lesion.
4. Treatment Plan: A documented treatment plan that outlines conservative management strategies, referrals to physical therapy, or surgical interventions if necessary.
5. Follow-up Documentation: Notes from follow-up visits that monitor progress and response to treatment, reinforcing the ongoing nature of the condition.

Subjective: A 52-year-old female presents with complaints of sharp pain in her right shoulder that worsens with overhead activities and during the night. She reports difficulty reaching for items on a high shelf and occasional shoulder stiffness. Objective: On examination, the right shoulder shows limited range of motion, particularly in abduction and external rotation. There is tenderness noted over the supraspinatus tendon, and a positive Neer test was observed. Assessment: Right shoulder rotator cuff lesion, suspected tear, likely related to chronic overuse. Plan: Schedule an MRI to assess the extent of the lesion. Instruct the patient on physical therapy focusing on shoulder strengthening and range-of-motion exercises. Discuss pain management options including NSAIDs and consider a follow-up visit in four weeks.

When evaluating shoulder lesions, it is essential to consider differential diagnoses:

1. Rotator Cuff Tear (M75.121): Characterized by specific weakness in arm elevation.
2. Shoulder Impingement Syndrome (M75.120): Presents with pain during overhead activities without significant weakness.
3. Labral Tear (S43.42): Often associated with clicking or locking sensations in the shoulder.
4. Frozen Shoulder (Adhesive Capsulitis) (M75.0): Characterized by severe stiffness and limited range of motion without acute pain.

Accurate documentation is essential for billing purposes under ICD-10 code M75.122:

1. Clearly document patient history, including onset, mechanism of injury, and previous treatments.
2. Record findings from physical examinations, including specific tests performed and their results.
3. Include imaging studies and their interpretations in the documentation.
4. Detail the treatment plan, including rehabilitation protocols followed.

Ensure that all documentation aligns with payer guidelines to facilitate proper reimbursement.