Orthopedic Coding Alert

Laterality guides your choice for partial and complete tears.

When you report non-traumatic rotator cuff tears in 2014, you need to answer two specific questions: Which shoulder was involved? Was the tear partial or complete?

What is Rotator Cuff?

The rotator cuff, formed by 4 muscles (Supraspinatus, infraspinatus, teres minor, and subscapularis), helps to stabilize the shoulder. These muscles arise from the scapula and insert into the humerus, thus forming a cuff around the shoulder joint.

Tears (partial or complete) can be caused by trauma or wear and tear. This leads to pain and restriction of movement at the shoulder joint. Injury to the rotator cuff occurs during motions that involve pulling or repeated overhead movements.

ICD-9 Options

When reporting rotator cuff tears, you select from ICD-9 codes 727.61 (Complete rupture of rotator cuff) or 726.13 (Partial tear of rotator cuff). Your choice is governed by the extent of the tear, i.e. if the tear is partial or complete.

Focus on Laterality

ICD-10 offers you a choice of the following codes for non-traumatic complete tear of the rotator cuff.

M75.120 -- Complete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic

M75.121 -- Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic

M75.122 -- Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic

Similarly, you get to choose from the following 3 codes for partial tears which are not traumatic in nature.

M75.110 -- Incomplete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic

M75.111 -- Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic

M75.112 -- Incomplete rotator cuff tear or rupture of left shoulder, not specified as traumatic

Documentation spotlight: The descriptors of these ICD-10 codes indicate the codes are appropriate for tears or ruptures "not specified as traumatic." You report these codes when your surgeon clearly documents that the tear was not caused by trauma. You also turn to these codes when your surgeon provides no documentation to support if the tear was traumatic or non-traumatic in nature.

Tip: If the documentation doesn’t specify complete or partial, you may turn to M75.100 (Unspecified rotator cuff tear or rupture, not specified as traumatic). The corresponding ICD-9 code is 726.10 (Disorders of bursae and tendons in shoulder region unspecified).