Shoulder lesions — ICD-10 M75.31

ICD-10: M75.31 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions encompass a variety of conditions affecting the structures of the shoulder joint, including tendons, ligaments, cartilage, and bones. They are classified under ICD-10 code M75.31 and can significantly impact an individual's range of motion, strength, and overall quality of life. Common shoulder lesions include rotator cuff tears, labral tears, and biceps tendon injuries. These conditions often arise from acute trauma or chronic overuse, particularly in athletes and individuals engaged in repetitive overhead activities.

The shoulder joint is a complex structure composed of the humerus, scapula, and clavicle, along with various soft tissues that provide stability and facilitate movement. Key anatomical components include:

• Rotator Cuff: Comprised of four muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that stabilize the humeral head within the glenoid cavity.
• Glenoid Labrum: A fibrocartilaginous rim that deepens the socket of the shoulder joint, providing additional stability.
• Biceps Brachii: The long head of this muscle attaches to the superior labrum and plays a role in shoulder stability and movement.
• Acromioclavicular Joint: The joint between the acromion process of the scapula and the clavicle.

Biomechanically, the shoulder allows for a wide range of motion, including flexion, extension, abduction, adduction, internal rotation, and external rotation. This extensive mobility makes the shoulder susceptible to injuries from both traumatic events and repetitive strain.

Patient presents with a 45-year-old female who reports persistent pain in the right shoulder after a fall while gardening. Upon examination, there is tenderness over the rotator cuff and limited range of motion. Code as M75.31 because the documentation supports a diagnosis of shoulder lesion due to an acute injury, which aligns with the guidelines for coding shoulder lesions under ICD-10-CM.

To support medical necessity and prevent claim denials for the M75.31 code, key documentation elements must include:

1. Detailed Patient History: Document the onset, duration, and characteristics of the shoulder pain, including any precipitating events or prior treatments.

1. Physical Examination Findings: Clearly describe the examination results, including any range of motion limitations, specific tenderness locations, and functional tests performed.

1. Diagnostic Imaging: Include results from imaging studies (e.g., X-rays, MRI) that confirm the presence of a shoulder lesion or associated pathology.

1. Treatment Plan: Outline the conservative management strategies attempted, including physical therapy, medication, or surgical interventions if applicable.

1. Follow-up Documentation: Document any changes in the patient’s condition during follow-up visits, as well as the effectiveness of the treatment plan.

Subjective: A 60-year-old male patient presents with complaints of right shoulder pain that has gradually worsened over the past three months. The pain is exacerbated by overhead activities and is associated with intermittent swelling. Objective: Physical examination reveals tenderness to palpation over the greater tuberosity of the humerus, positive impingement signs, and limited abduction of the right shoulder. X-rays show no fractures, but MRI indicates a partial tear of the rotator cuff. Assessment: Right shoulder lesion (M75.31) secondary to rotator cuff tear. Plan: Initiate a conservative treatment plan involving physical therapy focused on strengthening and improving range of motion. Consider corticosteroid injections if symptoms persist. Schedule a follow-up appointment in six weeks to reassess.

When diagnosing shoulder lesions, it’s essential to differentiate them from other conditions that may present similarly:

1. Rotator Cuff Tear (M75.121): Involves damage to one or more rotator cuff tendons.
2. Shoulder Impingement Syndrome (M75.4): Caused by compression of rotator cuff tendons beneath the acromion.
3. Biceps Tendon Rupture (M66.9): Involves tearing of the biceps tendon at its attachment point.
4. Labral Tear (M75.32): Damage to the glenoid labrum affecting joint stability.
5. Adhesive Capsulitis (M75.0): Characterized by stiffness and pain due to inflammation of the shoulder capsule.

Accurate documentation is crucial for billing purposes under ICD-10 code M75.31:

Key Elements for Documentation:

1. Detailed patient history including mechanism of injury.
2. Comprehensive physical examination findings.
3. Results from imaging studies supporting diagnosis.
4. Treatment plans including conservative management strategies.

Billing Guidance:

Ensure that all relevant codes are included in claims submissions based on specific findings related to the lesion type (e.g., M75.121 for rotator cuff tears). Utilize modifiers as necessary to indicate whether services were bilateral or if there were multiple procedures performed during a single visit.