Shoulder lesions — ICD-10 M75.5

ICD-10: M75.5 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions, classified under ICD-10 code M75.5, encompass a variety of injuries and conditions affecting the soft tissues and structures around the shoulder joint. These lesions can involve the muscles, tendons, ligaments, and cartilage that contribute to the shoulder's complex functionality. Clinically, shoulder lesions are often associated with pain, reduced range of motion, and functional impairment, significantly impacting daily activities and quality of life.

Shoulder lesions can arise from acute injuries or chronic overuse, making them prevalent among athletes and individuals engaged in repetitive overhead activities. Understanding the underlying anatomy, biomechanics, and pathophysiology is crucial for accurate diagnosis and effective management.

The shoulder joint consists of several key anatomical structures:

• Glenohumeral Joint: This ball-and-socket joint allows for a wide range of motion but is inherently unstable due to its shallow socket.
• Rotator Cuff: Comprising four muscles (supraspinatus, infraspinatus, teres minor, subscapularis), the rotator cuff stabilizes the humeral head within the glenoid cavity.
• Biceps Tendon: The long head of the biceps tendon also plays a role in shoulder stability and movement.
• Labrum: A fibrocartilaginous structure that deepens the glenoid cavity, providing additional stability to the shoulder joint.

Biomechanically, the shoulder joint's design allows for significant mobility at the expense of stability. This unique arrangement makes it susceptible to injuries such as tears, impingement syndromes, and tendinopathies. The rotator cuff muscles work synergistically to facilitate shoulder movements while maintaining joint congruence.

Patient presents with right shoulder pain that has persisted for six months, accompanied by limited range of motion and tenderness upon palpation. After a thorough examination and diagnostic imaging, a diagnosis of rotator cuff tear is made. Code as M75.5 because this code encompasses shoulder lesions, including rotator cuff tears, which are documented as the primary diagnosis.

To support medical necessity and prevent claim denials for ICD-10 Code M75.5, the following documentation elements are essential:

1. Detailed History: Document the onset, duration, and characteristics of shoulder symptoms to establish a clear clinical picture.

1. Physical Examination Findings: Include specific findings from the physical examination, such as range of motion measurements, tenderness locations, and results of special tests.

1. Diagnostic Imaging Reports: Ensure that any imaging studies (e.g., MRI, X-rays) are documented and clearly linked to the diagnosis of shoulder lesions.

1. Treatment Plan: Outline the proposed treatment plan, including conservative measures attempted and the rationale for any further interventions.

1. Follow-Up Documentation: Record any follow-up visits, patient responses to treatments, and adjustments made to the treatment plan based on patient progress.

Subjective: A 54-year-old female patient presents with complaints of persistent pain in her right shoulder for the past four months, stating that it worsens with overhead activities and during sleep. She reports no history of trauma. Objective: Physical examination reveals tenderness to palpation over the greater tuberosity of the humerus and positive Neer and Hawkins-Kennedy tests. Range of motion is limited, especially in abduction and external rotation. MRI results indicate a partial thickness tear of the supraspinatus tendon. Assessment: Right shoulder lesion (ICD-10 Code M75.5) due to a partial thickness tear of the rotator cuff. Plan: Initiate a conservative treatment plan including physical therapy focused on strengthening and stretching exercises. Consider a follow-up visit in six weeks to assess progress, with the option for corticosteroid injection if symptoms persist.

Several conditions may mimic shoulder lesions:

1. Rotator Cuff Tear (M75.1): Complete or partial tear involving rotator cuff tendons.
2. Shoulder Impingement Syndrome (M75.4): Compression of rotator cuff tendons beneath the acromion leading to pain and dysfunction.
3. Biceps Tendon Rupture (M75.2): Injury to the long head of the biceps tendon presenting with specific symptoms.
4. Frozen Shoulder (Adhesive Capsulitis) (M75.0): Characterized by stiffness and pain due to inflammation of the shoulder capsule.

Differentiating these conditions is critical for appropriate management.

Accurate documentation is essential for billing purposes under ICD-10 code M75.5:

1. Clearly document patient history, physical examination findings, imaging results, and treatment plans.
2. Use specific codes for differential diagnoses when applicable (e.g., M75.1 for rotator cuff tear).
3. Ensure that all services provided are documented in accordance with payer guidelines to facilitate reimbursement.

Proper coding not only aids in billing but also supports continuity of care through comprehensive medical records.