Reduce Your Coding Confusion for 3 Common Shoulder Injuries
Find out the common term for adhesive capsulitis. The shoulder is one of the most complex joints in the human body and it is used in a wide variety of ways throughout the day. With the amount of wear and tear placed on the shoulder, the joint is susceptible to injuries that can cause immense pain for the patient. As an orthopedic coder, you need to familiarize yourself with the different conditions that can affect the shoulder joint. Read on to learn about three common shoulder injuries and how to locate their correct ICD-10-CM codes. Get to Know the Anatomy of the Shoulder The joint is made of three bones, which include the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone). The bones connect to form the shoulder joint, and a network of muscles, tendons, and ligaments hold the bones together stabilize them for reliable movements. A group of muscles and tendons, known as the rotator cuff, secure the humerus within the socket. Understanding the different anatomical structures of the shoulder joint will help you accurately code shoulder injuries. Identify the Impingement Diagnosis Codes One common shoulder condition is shoulder impingement. This condition occurs when the shoulder muscles rub against the acromion (top part of the shoulder blade) and the coracoid process (hook-like bump under the clavicle) of the shoulder blade. Impingement develops during activities requiring excessive overhead arm motions such as tennis serves, throwing a baseball, or swimming. Find the code: In the ICD-10-CM Alphabetic Index, search for Syndrome > impingement, shoulder, and you’ll arrive at M75.4- (Impingement syndrome of shoulder), which you’ll verify in the Tabular List. In the Tabular List, you’ll find that M75.4- requires a 5th character to complete the code. The 5th character specifies the left, right, or unspecified shoulder, as follows: Heat Up Your Frozen Shoulder Coding Shoulder impingement that persists and is left untreated can become adhesive capsulitis, which is also known as frozen shoulder. Frozen shoulder symptoms include pain and stiffness in the shoulder joint, and the symptoms often start gradually and worsen over time. Frozen shoulders affect patients primarily between ages 40 and 60 years old. The condition can develop when the patient uses the joint intermittently. Meanwhile, inflammation can occur and adhesions can grow between the joint surfaces, which ultimately restricts movement. The joint space also lacks synovial fluid to lubricate the space between the socket and the humerus. Find the code: Open the Alphabetic Index and search for Capsulitis (joint) > adhesive (shoulder) to find M75.0- (Adhesive capsulitis of shoulder). When you turn to the Tabular List to verify the code, you’ll find that a 5th character is required to identify the laterality and complete the code. Use the following codes to report a frozen shoulder diagnosis: You will also find that frozen shoulder is an additional diagnosis term listed under M75.0-. Learn How to Recognize Shoulder Dislocation Codes A patient experiences shoulder dislocation when the head of the humerus is forced out of the shoulder socket. The dislocation can occur for several reasons, including as a result of a fall, an injury to the shoulder, or overuse of the joint. Patients suffering from a dislocated shoulder may experience severe pain, inability to move the joint, swelling, bruising, and the shoulder may visibly appear out of place. Find the code: Locate the shoulder dislocation diagnosis codes by searching for Dislocation (articular) > shoulder in the Alphabetic Index. You’ll be directed to the S43.0- (Subluxation and dislocation of shoulder joint) code subcategory in the Tabular List. Under the Tabular List, there are several more subcategories that specify the type of dislocation: An anterior dislocation of humerus means the head of the humerus bone moves forward out of the shoulder socket toward the front of the patient’s body. With a posterior dislocation of the humerus, the head of the humerus is moved backward out of the socket. During an inferior dislocation of the humerus, the humerus bone is forced up and out of the socket. The patient’s arm appears to be permanently held upward with an inferior dislocation — this is the least common type of shoulder dislocation. In each subcategory, you’ll use a 6th character to identify the laterality of the injury. You’re also required to append a 7th character, as follows: Scenario: A patient presents to an urgent care with a shoulder injury sustained during a football game. The patient was tackled trying to throw a pass and dislocated their right shoulder. Following a history, physical examination, and X-rays, the orthopedist diagnosed the patient with a posterior right shoulder dislocation. In this scenario, you’ll assign S43.024A (Posterior dislocation of right humerus, initial encounter) to report the diagnosis. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
