M75.40 - Impingement syndrome of unspecified shoulder (ICD-10)
ICD-10 code M75.40 - Impingement syndrome of unspecified shoulder. Classified under Other soft tissue disorders, not elsewhere classified, this condition involves clinical findings relevant to diagnosis and documentation accuracy.
Overview
Shoulder disorders, including rotator cuff injuries and frozen shoulder, are common causes of upper limb disability. Early recognition and therapy help restore motion and prevent chronic stiffness.
- Document acuity (acute, subacute, chronic).
- Include anatomic region/level and laterality.
- Correlate symptoms with exam and imaging when used.
- Avoid unspecified codes when details exist in the note.
- Verify payer policy/LCD before procedures.
- Ensure medical necessity is explicit.
Comman symptoms
- Shoulder pain with overhead activity or at night
- Weakness or limited abduction/external rotation
- Capsular pattern loss if frozen shoulder
Red Flag
- Severe or progressive neurologic deficit
- Fever unexplained weight loss night sweats
- History of cancer immunosuppression or IV drug use
- Trauma with suspected fracture
- Bowel/bladder dysfunction or saddle anesthesia
At a Glance
- ICD-10 code: M75.40
- Condition: Impingement syndrome of unspecified shoulder
- Category: Shoulder Disorders (Rotator Cuff, Adhesive Capsulitis)
- Related ICD-10 codes: M75.00-M75.02, M75.10-M75.12, M75.40-M75.42
- Common CPT links: 99202-99215, 20610, 97014/G0283, 97110, 97140, 73030 (imaging)
- Use the most specific laterality/region code your note supports.
Overview
Shoulder disorders, including rotator cuff injuries and frozen shoulder, are common causes of upper limb disability. Early recognition and therapy help restore motion and prevent chronic stiffness.
- Document acuity (acute, subacute, chronic).
- Include anatomic region/level and laterality.
- Correlate symptoms with exam and imaging when used.
- Avoid unspecified codes when details exist in the note.
- Verify payer policy/LCD before procedures.
- Ensure medical necessity is explicit.
Causes & Risk Factors
Impingement syndrome of unspecified shoulder (M75.40) can arise from a combination of biomechanical stress, degenerative processes, systemic inflammation, or trauma. Common risk factors include aging, occupational strain, obesity, and genetic predisposition. Lifestyle factors such as poor posture, repetitive movement, or low physical conditioning also contribute to chronic musculoskeletal pain.
Diagnostic Workup
Accurate coding of Impingement syndrome of unspecified shoulder requires clear diagnostic workup. Clinicians often rely on physical examination findings such as range of motion limits, palpation tenderness, or neurovascular testing. Imaging-X-ray, MRI, or ultrasound-may confirm degenerative, inflammatory, or structural changes. Laboratory tests are typically ordered if autoimmune or metabolic causes are suspected.
Treatment & Rehabilitation
While this resource focuses on ICD-10 coding, understanding general management helps coders interpret documentation. Treatment for Impingement syndrome of unspecified shoulder may include physical therapy, posture correction, ergonomic modifications, or supervised exercise programs. Pharmacologic therapy and procedural interventions should be captured through appropriate CPT and HCPCS codes when documented. Rehabilitation aims to restore strength, range of motion, and prevent recurrence.
Prevention
Preventing recurrent musculoskeletal issues requires a holistic approach-educating patients on stretching routines, core strengthening, and activity modification. For clinicians, structured documentation templates and s can ensure accurate, defensible coding for audit readiness.
Coding Examples
- Example 1: Patient with impingement syndrome of unspecified shoulder and documented left-sided involvement - code M75.40-L.
- Example 2: Chronic pain after prior injury with imaging-confirmed degeneration - use M75.40 with chronicity modifier where applicable.
- Example 3: Bilateral presentation with limited range of motion - choose most specific laterality code variants.
Audit & Compliance
Ensure ICD-10 coding aligns with payer policies and medical necessity. Redundant use of unspecified codes is a common audit trigger. For complex cases, link diagnosis codes to procedure CPTs in the superbill and verify that documentation supports frequency and modality of care.
Clinical Example
Chief Complaint: Patient presents with impingement syndrome of unspecified shoulder over the past several weeks reporting intermittent pain and reduced function.
Subjective: The patient describes symptoms as dull aching and aggravated by movement or prolonged posture. Pain score rated 6/10 relieved partially by rest or heat.
Objective: Physical examination reveals localized tenderness reduced range of motion and no neurological deficit. Imaging reviewed indicates findings consistent with impingement syndrome of unspecified shoulder (M75.40).
Assessment: Impingement syndrome of unspecified shoulder (M75.40) - consistent with shoulder disorders (rotator cuff
adhesive capsulitis).
Plan: Continue conservative management monitor progression and re-evaluate in 4-6 weeks. Documentation supports ICD-10 code usage as primary diagnosis.
Differential Diagnoses
When coding impingement syndrome of unspecified shoulder, consider alternative or coexisting conditions that may share similar symptoms. Accurate differentiation ensures correct ICD-10 assignment and proper claim justification.
- Subacromial impingement
- Biceps tendinopathy
- Labral tear
- Arthritis of the glenohumeral joint
Documentation Best Practices
- Document acuity (acute subacute chronic) and laterality when available.
- Capture specific region/level (e.g. cervical vs lumbar; right vs left; primary vs secondary OA).
- Link symptoms to exam and imaging findings when relevant; avoid unsupported specificity.
- Use the most specific code supported by the note; avoid unspecified when details exist.
- Check payer policy and NCD/LCD rules; include conservative care attempts if required.
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Under ICD‑10, M75.40 refers to Impingement syndrome of unspecified shoulder and is grouped in Other soft tissue disorders, not elsewhere classified. Choose it when the assessment clearly supports this diagnosis and alternative causes have been considered. For example, a patient with impingement syndrome of unspecified shoulder may present after activity or posture strain; documentation should reflect measurable limits and reproducible findings. Maintain concise, specific language and update coding as facts evolve. If details are missing initially, update the code at follow‑up once specifics are recorded. When imaging is referenced, summarize key findings that support the diagnosis. When imaging is referenced, summarize key findings that support the diagnosis. When imaging is referenced, summarize key findings that support the diagnosis. When imaging is referenced, summarize key findings that support the diagnosis.
ICD‑10 M75.40 describes Impingement syndrome of unspecified shoulder within the Other soft tissue disorders, not elsewhere classified category. Unspecified coding is a fallback only if the chart genuinely lacks details; add specificity at follow‑up once facts are documented. If your note has side, region, acuity, or etiology, select the sub‑code that reflects those details rather than M75.40 unspecified. Use precise terminology and reflect clinical reasoning to support compliant coding. When imaging is referenced, summarize key findings that support the diagnosis. Document functional impact in the history and align it with the plan. When imaging is referenced, summarize key findings that support the diagnosis. If details are missing initially, update the code at follow‑up once specifics are recorded. When imaging is referenced, summarize key findings that support the diagnosis.
M75.40 in ICD‑10 captures Impingement syndrome of unspecified shoulder; it sits in the Other soft tissue disorders, not elsewhere classified section. Related ICD‑10 options include more specific laterality/region codes; pair only with procedures supported by the note and payer rules. Always ensure medical necessity and precise diagnosis‑procedure linkage; avoid pairing symptom codes once M75.40 is established. Maintain concise, specific language and update coding as facts evolve. If details are missing initially, update the code at follow‑up once specifics are recorded. Document functional impact in the history and align it with the plan. If details are missing initially, update the code at follow‑up once specifics are recorded. If details are missing initially, update the code at follow‑up once specifics are recorded.
Under ICD‑10, M75.40 refers to Impingement syndrome of unspecified shoulder and is grouped in Other soft tissue disorders, not elsewhere classified. Your note should capture onset and duration, location or laterality, severity, functional impact, and relevant exam findings. Include objective measures (ROM, strength, special tests) and summarize prior management or red‑flags as applicable. Clarity and specificity in documentation improve claim success and audit readiness. If details are missing initially, update the code at follow‑up once specifics are recorded. When imaging is referenced, summarize key findings that support the diagnosis. Document functional impact in the history and align it with the plan. If details are missing initially, update the code at follow‑up once specifics are recorded. If details are missing initially, update the code at follow‑up once specifics are recorded.
Under ICD‑10, M75.40 refers to Impingement syndrome of unspecified shoulder and is grouped in Other soft tissue disorders, not elsewhere classified. Frequent denial reasons include unspecified coding despite available details, weak linkage between diagnosis and procedures, and missing conservative care notes. Prevent issues by aligning assessment, plan, and any procedures to the diagnosis, and cite payer LCD/NCD rules when relevant. Maintain concise, specific language and update coding as facts evolve. If details are missing initially, update the code at follow‑up once specifics are recorded. If details are missing initially, update the code at follow‑up once specifics are recorded. When imaging is referenced, summarize key findings that support the diagnosis. If details are missing initially, update the code at follow‑up once specifics are recorded.
