Shoulder lesions — ICD-10 M75.82

ICD-10: M75.82 | Category: Soft Tissue Disorders | Billable: Yes

Shoulder lesions encompass a variety of injuries and degenerative conditions affecting the structures within the shoulder joint, including tendons, ligaments, cartilage, and bones. ICD-10 code M75.82 specifically refers to unspecified lesions of the shoulder region. These lesions can result from acute trauma or chronic overuse, leading to pain, dysfunction, and reduced range of motion. Understanding shoulder lesions is crucial for clinicians, rehabilitation providers, and patients alike, as timely diagnosis and appropriate management can significantly improve outcomes.

The shoulder is one of the most mobile joints in the human body, composed of several key anatomical structures:

1. Bones: The shoulder girdle consists of three primary bones: the humerus (upper arm), scapula (shoulder blade), and clavicle (collarbone).
2. Joints: The glenohumeral joint (the ball-and-socket joint) allows for a wide range of motion. The acromioclavicular (AC) joint and sternoclavicular (SC) joint also contribute to shoulder function.
3. Muscles: The rotator cuff comprises four muscles (supraspinatus, infraspinatus, teres minor, and subscapularis) that stabilize the shoulder during movement.
4. Tendons and Ligaments: Tendons connect muscles to bones, while ligaments connect bones to other bones. The labrum is a fibrocartilaginous structure that deepens the glenoid cavity.

Biomechanically, the shoulder's design allows for extensive mobility; however, this comes at the cost of stability. The rotator cuff muscles play a vital role in maintaining joint stability during dynamic activities such as throwing or lifting.

Patient presents with right shoulder pain and limited range of motion following a fall while playing tennis. Upon examination, the physician notes tenderness in the shoulder joint and signs of a rotator cuff tear. Code as M75.82 because the documentation supports the diagnosis of a shoulder lesion due to trauma, which is specifically classified under this code in the ICD-10-CM guidelines.

To support medical necessity and prevent claim denials for ICD-10 code M75.82, the following key documentation elements must be included:

• A clear description of the patient's symptoms and their duration.
• Detailed physical examination findings, including range of motion and strength assessments.
• A definitive diagnosis that correlates with the ICD-10 code selected, supported by clinical findings.
• Documentation of any imaging studies or diagnostic tests performed, if applicable.
• Evidence of treatment plans, including referrals to physical therapy or follow-up appointments, which reflects the management of the condition.

Subjective: A 45-year-old female patient reports persistent pain in her right shoulder that started two weeks ago after lifting a heavy box. She describes the pain as sharp and radiating down her arm, worsened by overhead activities and at night. Objective: On examination, the right shoulder exhibits limited range of motion, particularly in abduction and external rotation. There is tenderness over the greater tuberosity, and the patient demonstrates weakness in the supraspinatus muscle during strength testing. No swelling or deformity is noted. Assessment: Right shoulder lesion due to overuse injury, likely involving the rotator cuff, consistent with ICD-10 code M75.82. Plan: Initiate a physical therapy regimen focusing on strengthening and flexibility exercises. Consider prescribing NSAIDs for pain management. Schedule a follow-up in four weeks to assess progress and consider imaging if symptoms persist.

When evaluating shoulder lesions, it’s important to differentiate them from other conditions:

1. Rotator Cuff Tear (ICD-10 Code M75.121): Acute or chronic tears affecting rotator cuff tendons.
2. Shoulder Impingement Syndrome (ICD-10 Code M75.41): Caused by compression of rotator cuff tendons under the acromion.
3. Frozen Shoulder (Adhesive Capsulitis) (ICD-10 Code M75.0): Characterized by stiffness and pain due to inflammation of the shoulder capsule.
4. Acromioclavicular Joint Injury (ICD-10 Code S43.0): Injuries affecting the AC joint often due to trauma.

To ensure accurate coding and support medical necessity for ICD-10 code M75.82, consider the following documentation strategies:

1. Comprehensive Clinical History: Document the onset, duration, and severity of symptoms, including any aggravating or alleviating factors. This information supports the diagnosis and justifies the need for imaging or further intervention.
2. Detailed Physical Examination Findings: Clearly document findings such as tenderness, range of motion, strength testing, and any neurological deficits. Specificity in these details can strengthen the case for medical necessity.
3. Use of Specific Terminology: Avoid vague terms. Instead of "shoulder pain," specify "anterior shoulder pain" or "lateral shoulder pain" to provide clarity on the nature of the lesion.
4. Imaging and Diagnostic Tests: Include results from any imaging studies (e.g., X-rays, MRI) that confirm the diagnosis of a shoulder lesion. Ensure that these findings are linked to the specific ICD-10 code.
5. Treatment Plan Documentation: Outline the treatment plan, including conservative management (e.g., physical therapy, corticosteroid injections) or surgical interventions, and document the patient's response to treatment to support ongoing medical necessity.
6. Follow-Up Recommendations: Clearly note follow-up appointments or further evaluations to monitor the progression of the condition, which can aid in justifying continued treatment and coding.