Shoulder lesions — ICD-10 M75.3

ICD-10: M75.3 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions, classified under ICD-10 code M75.3, encompass a variety of injuries and degenerative conditions affecting the structures surrounding the shoulder joint, including muscles, tendons, ligaments, and the joint capsule itself. These lesions can result from acute trauma, repetitive stress, or degenerative changes due to aging. Common types of shoulder lesions include rotator cuff tears, labral tears, and impingement syndromes, which can lead to significant pain and functional impairment.

Understanding shoulder lesions is crucial for clinicians, rehabilitation providers, and patients alike. This article delves into the anatomy and biomechanics of the shoulder, the pathophysiology and risk factors associated with lesions, clinical presentations based on severity, diagnostic evaluations, treatment protocols, prognosis, and billing guidance.

The shoulder is a complex structure composed of bones, muscles, tendons, and ligaments that work together to provide a wide range of motion while maintaining stability. Key anatomical components include:

• Bones: The shoulder girdle consists of the humerus (upper arm bone), scapula (shoulder blade), and clavicle (collarbone). The glenohumeral joint is formed by the head of the humerus fitting into the shallow glenoid cavity of the scapula.

• Muscles: The rotator cuff comprises four muscles—supraspinatus, infraspinatus, teres minor, and subscapularis—that stabilize the humeral head within the glenoid cavity during arm movements.

• Tendons: These structures connect muscles to bones and play a vital role in shoulder motion. The rotator cuff tendons are particularly susceptible to injury.

• Ligaments: The shoulder joint is stabilized by several ligaments, including the glenohumeral ligaments and the coracohumeral ligament.

The biomechanics of the shoulder allow for an extensive range of motion; however, this mobility comes at the cost of stability. The dynamic stabilization provided by the rotator cuff muscles is essential for optimal shoulder function.

Patient presents with persistent left shoulder pain following a recent fall while playing tennis. Upon examination, the physician notes tenderness and limited range of motion in the left shoulder. Code as M75.3 because the documentation indicates a shoulder lesion due to trauma, aligning with the ICD-10 guidelines for coding lesions of the shoulder region.

To support medical necessity and prevent claim denials for the ICD-10 code M75.3, ensure the following key documentation elements are included:

1. A thorough history that includes the onset of symptoms, mechanism of injury, and any prior treatment.
2. Detailed physical examination findings, highlighting specific range of motion deficits and tenderness locations.
3. Clear diagnostic assessment establishing the presence of a shoulder lesion.
4. A comprehensive treatment plan, including referrals for physical therapy or imaging if necessary.
5. Documentation must justify the patient's condition, demonstrating the impact on daily activities and the need for ongoing management.

Subjective: A 54-year-old female patient reports chronic pain in her right shoulder that has worsened over the past three months. She describes the pain as sharp, particularly when reaching overhead or lifting objects. She denies any history of trauma. Objective: On physical examination, the patient exhibits limited range of motion in the right shoulder, with significant tenderness over the supraspinatus tendon. No swelling or deformity is noted. Strength testing reveals weakness in abduction and external rotation. Assessment: Right shoulder lesion consistent with rotator cuff pathology, likely due to overuse and degenerative changes. Plan: Initiate physical therapy focusing on strengthening and range-of-motion exercises. Prescribe NSAIDs for pain management. Schedule a follow-up in four weeks to assess progress and consider imaging if symptoms do not improve.

Differentiating between various shoulder conditions is critical:

1. Rotator Cuff Tear (M75.1): Characterized by tears in one or more rotator cuff tendons.
2. Shoulder Impingement Syndrome (M75.4): Involves compression of rotator cuff tendons beneath the acromion.
3. Glenoid Labrum Tear (M75.2): Injury to the fibrocartilaginous rim surrounding the glenoid cavity.
4. Adhesive Capsulitis (M75.0): Also known as frozen shoulder; characterized by stiffness and pain.

Accurate documentation is crucial for billing purposes related to ICD code M75.3:

1. Document patient history comprehensively, including mechanism of injury and symptom duration.
2. Include findings from physical examinations, special tests performed, and imaging results.
3. Clearly outline treatment plans implemented during each visit along with patient responses to therapies.
4. Use appropriate modifiers when applicable to indicate any additional services rendered during visits.