Orthopedic Coding Alert

Question: In the impression of the report, the provider documents that “contrast opacification of the subacromial and subdeltoid bursa is indicative of a rotator cuff tear.” Is this sufficient documentation to code a rotator cuff tear?

Wisconsin Subscriber

Answer: There are numerous instances where the terminology behind a particular diagnosis can rule it out from being reported as a diagnosis code. The most common offenders are terms such as “probable,” “likely,” “suspected,” etc. However, if the provider documents that a particular set of findings is “indicative” of a diagnosis, then you might consider that diagnosis a definitive finding if you cannot get more information from the provider.

In this instance, the provider is trained to identify a rotator cuff tear when the imaging presents contrast opacification of the subacromial and subdeltoid bursa. In other instances, such as the documentation of an opacity on a chest x-ray, the provider may be more inclined the speculative as to the etiological origins of the finding. If the provider speculates further beyond stating that an opacity exists, they will most likely refrain from using a term as clear-cut as “indicative.”

Warning: You should do all you can to check with the provider for more information before deciding to use an ICD-10 code from the M75.10- (Unspecified rotator cuff tear or rupture, not specified as traumatic) through M75.12- (Complete rotator cuff tear or rupture not specified as traumatic) code set. Many experts advise coding a condition based on phrasing in the notes — no matter how indicative they might seem of a certain condition.

Ultimately it’s your call, but if you don’t get that confirmation of a rotator cuff tear, you might be better off going with a less specific, but more accurate, ICD-10 codes for this patient’s condition. This might be a moment where you can explain to the provider that you’ll need more specific language in the notes to come to an absolute, definitive diagnosis.