Shoulder lesions — ICD-10 M75.81

ICD-10: M75.81 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions, classified under ICD-10 code M75.81, refer to a variety of injuries or degenerative changes affecting the structures of the shoulder joint. This condition encompasses a range of issues, including rotator cuff tears, labral tears, and other soft tissue injuries that can lead to pain, weakness, and functional impairment. The shoulder is a highly mobile joint, allowing for a wide range of motion, which makes it susceptible to injuries from acute trauma or chronic overuse.

The clinical definition of shoulder lesions includes damage to the rotator cuff muscles and tendons, glenoid labrum, and surrounding soft tissues. These injuries can arise from various mechanisms, including sports activities, repetitive overhead motions, or direct trauma.

The shoulder joint is a complex structure composed of several key anatomical components:

• Glenohumeral Joint: The ball-and-socket joint formed by the humeral head and the glenoid cavity of the scapula.
• Rotator Cuff: A group of four muscles—supraspinatus, infraspinatus, teres minor, and subscapularis—that stabilize the shoulder and facilitate movement.
• Labrum: A fibrocartilaginous structure that deepens the glenoid cavity and provides stability to the shoulder joint.
• Bursa: Fluid-filled sacs that reduce friction between tissues during movement.
• Deltoid Muscle: The muscle responsible for lifting the arm and giving the shoulder its rounded shape.

Biomechanically, the shoulder relies on a delicate balance of muscle strength, coordination, and joint integrity to perform various activities ranging from reaching overhead to throwing. The rotator cuff plays a crucial role in stabilizing the humeral head within the shallow glenoid cavity during dynamic movements.

Patient presents with persistent right shoulder pain following a fall while playing basketball. Upon examination, the physician notes tenderness and swelling in the shoulder joint with limited range of motion. Code as M75.81 because the diagnosis aligns with the presence of a shoulder lesion, specifically an injury resulting from the fall, that affects the shoulder structure.

To support medical necessity for ICD-10 code M75.81 and prevent claim denials, key documentation elements include:

1. Detailed Patient History: Document the onset, duration, and nature of symptoms, including any traumatic events leading to the condition.
2. Clinical Findings: Clearly describe physical examination results, including specific findings related to shoulder range of motion and tenderness.
3. Diagnostic Imaging: Include results from imaging studies, like MRI or X-rays, that confirm the diagnosis of shoulder lesions.
4. Treatment Plan: Outline a comprehensive treatment plan that includes conservative measures (e.g., physical therapy) and any referrals made for further evaluation.
5. Follow-Up Documentation: Record follow-up visits to assess treatment progress and adjust the plan as needed, ensuring continuity of care is evident.

Subjective: A 45-year-old male patient reports a 3-month history of worsening pain in the right shoulder, which he attributes to a fall during a recent basketball game. He describes the pain as sharp and worsening with overhead activities. Objective: Upon examination, the right shoulder exhibits swelling and tenderness over the greater tuberosity. Range of motion is limited, particularly in abduction and external rotation. X-rays show no fractures, but MRI indicates a partial rotator cuff tear and subacromial bursitis. Assessment: Right shoulder lesion (partial rotator cuff tear) secondary to trauma. Plan: Initiate a physical therapy regimen focusing on range of motion and strengthening exercises. Consider corticosteroid injection if symptoms do not improve in 4 weeks. Schedule follow-up in 6 weeks to reassess shoulder function and pain levels.

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

1. Rotator Cuff Tear (M75.121 - Unilateral rotator cuff tear, not specified as traumatic)
2. Shoulder Impingement Syndrome (M75.41 - Impingement syndrome of shoulder)
3. Glenoid Labral Tear (M75.82 - Other specified disorders of shoulder)
4. Adhesive Capsulitis (M75.0 - Frozen shoulder)
5. Shoulder Bursitis (M70.51 - Bursitis of shoulder)

Differentiating these conditions is crucial for appropriate management.

Accurate documentation is critical for billing purposes under ICD-10 code M75.81:

Documentation Tips:

1. Clearly document patient history including onset, duration, and impact on daily life.
2. Record all physical examination findings thoroughly.
3. Include results from imaging studies that support your diagnosis.

Billing Guidance:

Ensure that all services rendered are appropriately coded according to the specific interventions performed during visits, including physical therapy sessions or diagnostic imaging as necessary.