Rotator Cuff Tear and Shoulder Lesions ICD-10-CM codes

Rotator cuff tears that are degenerative or not documented as traumatic are coded to M75.1-. The 5th character reports the tear type (0 unspecified, 1 incomplete or partial-thickness, 2 complete or full-thickness) and the 6th character the side (0 unspecified, 1 right, 2 left). A full-thickness tear of the left supraspinatus without a documented injury is M75.122; a tear of unspecified type in the right shoulder is M75.101. Because the code title reads not specified as traumatic, M75.1- is the default when the mechanism is unclear.

When the provider documents an acute injury as the cause, use chapter 19 instead: S46.01- for a strain of the rotator cuff, S46.02- for a laceration, or S46.00- for an unspecified rotator cuff injury, each with laterality and a 7th character (A initial, D subsequent, S sequela). A sprain of the rotator cuff capsule is S43.42-. M75.1- carries an Excludes1 note for traumatic tears, so the two are not reported together for the same shoulder.

The rest of M75 covers the other common shoulder diagnoses: M75.0- adhesive capsulitis (frozen shoulder), M75.2- bicipital tendinitis, M75.3- calcific tendinitis, M75.4- impingement syndrome, M75.5- bursitis of shoulder, and M75.8- other lesions, all with laterality. Shoulder pain without a diagnosis is M25.511 or M25.512 and is dropped once a lesion is confirmed.