EM Coding Alert

Question: Encounter notes indicate that the provider performed a level three ED E/M service for a patient with “supraspinatus synd, R shoulder.” How should I code this encounter? I don’t know what supraspinatus syndrome is, or how to choose an ICD-10 code for it.

Maine Subscriber

Answer: For the E/M, report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination, and medical decision making of moderate complexity).

Dx coding: You might not know the term supraspinatus syndrome, but you’ve probably heard other terms used for the injury. ICD-10 officially recognizes the M75.1- (Rotator cuff tear or rupture, not specified as traumatic) code set for supraspinatus syndrome. Other terms ICD-10 considers synonymous with the M75.1- descriptor are “rotator cuff syndrome” and “supraspinatus tear or rupture, not specified as traumatic.”

Your coding adventure doesn’t stop there, though, as you must still drill down to get the most accurate code possible for this patient’s injury.

Go back and look at the notes again, which will direct you to M75.10- (Unspecified rotator cuff tear or rupture, not specified as traumatic); then, choose one of the following ICD-10 codes for the patient’s injury:

• M75.101 (Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic)
• M75.111 (Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic)
• M75.121 (Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic).