Orthopedic Coding Alert

Key: Knowing the level of trauma will affect what code you use.

With so many moving parts and so many ways to damage those parts, coding injuries to the rotator cuff isn’t always straightforward. Check out many of the common rotator cuff codes and highlight what you need to do to avoid making a mistake.

Go In-Depth With Rotator Cuff Terminology

First, familiarize yourself with all the parts of the rotator cuff. Much of coding confusion stems from the unfamiliarity of language that a provider uses in her report. A report may indicate a specific muscle or tendon found in the rotator cuff, but you may not recognize the term, leaving you stuck flipping through medical manuals to figure out what to do next. Save yourself that time and keep your eyes out for these specific terms:

• Teres minor muscle
• Infraspinatus muscle
• Supraspinatus muscle
• Subscapularis muscle

Train yourself to recognize these terms in your provider’s report. By doing so, you can cut down on the time it takes to determine that any sprains, tears, ruptures, or lacerations to these parts of the body are to be coded as injuries to the rotator cuff.

Next, Define the Injury

After ensuring that you need to code for the rotator cuff, you need to pay attention to what kind of injury occurred. The two major injuries for rotator cuffs are tears and strains.

Tears and ruptures trip up a lot of coders. You must be savvy in order to determine whether or not the tear was complete, and you will also have to determine if the rupture was traumatic or nontraumatic.

Begin by determining the level of trauma.

Traumatic: Traumatic injuries occur when an impact or other detrimental cause damages the rotator cuff. An example of this is if the patient tries to lift a weight that is too heavy for him, such as the case of many weightlifters. If his body is unable to handle the weight during that lifting event, the tear can occur and this is considered traumatic. Sometimes your provider may refer to this as an acute tear.

Non-traumatic: Non-traumatic, by contrast, is a tear or rupture that occurs over time. This is often found in older patients whose muscles are not as strong as they used to be. These types of tears can be the result of years of use and is often referred to as a degenerative tear.

Once you determine the type of trauma, you can now assess if the tear is partial or complete. This is where your know-how of orthopedic vocabulary can come in handy.

Complete: A complete tear is when the tendon is completely torn from the bone. Usually, it is the supraspinatus muscle that is most commonly torn tendon.

Partial: A partial tear is when damage to the tendons or muscle occur, but they are not severed. This is known as a partial tear.

Finally, Put This Information Together

You can now report these codes easily.

Traumatic: Most traumatic codes are found in the S section of the ICD-10 manual, so if you determined the injury is traumatic, use the following codes:

• S46.011X (Strain of muscle[s] and tendon[s] of the rotator cuff of right shoulder)
• S46.012X (Strain of muscle[s] and tendon[s] of the rotator cuff of left shoulder)
• S46.021X (Laceration of muscle[s] and tendon[s] of the rotator cuff of the right shoulder)
• S46.022X (Laceration of muscle[s] and tendon[s] of the rotator cuff of the left shoulder)

Notice that even though the injury is named as a tear or rupture, it is defined in the code as a laceration. “It’s never called a laceration — it’s always called a rotator cuff tear” says Bill Mallon, MD,  former medical director, Triangle Orthopedic Associates, Durham, North Carolina “The coders will never see this in an op note.” If you see that the injury is a tear or rupture, still code for a laceration.

Non-traumatic: For non-traumatic codes, refer to the M section of your ICD-10-CM manual, listed below:

• M75.101 (Unspecified rotator cuff tear or rupture of right shoulder, not specified as traumatic)
• M75.102 (Unspecified rotator cuff tear or rupture of left 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)
• 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)

Most likely, these non-traumatic injuries will occur in older patients. “Most injuries consist of a tear or rupture that is the result of a degenerative process,” says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, with Coder on Call, Inc., in Milltown, New Jersey.

Heads up: Remember that these codes will require a seventh character to specify whether this encounter can be identified as initial, subsequent, or sequela.

Don’t Overlook Strains

Strains, on the other hand, are fairly easy. Unlike lacerations, you don’t have to make the distinction between a traumatic and non-traumatic injury. Strains are, by their nature, always traumatic. Therefore, their codes will be found in the S section of your ICD-10-CM manual. Also, be aware that strains do not have categories like complete or incomplete lacerations. The two codes you will need are:

• S46.011 (Strain of muscle[s] and tendon[s] of the rotator cuff of right shoulder)
• S46.012 (Strain of muscle[s] and tendon[s] of the cuff of left shoulder)

Avoid Unspecified Codes at All Costs

Lastly, you need to avoid ambiguity. Many of these codes have an unspecified option, but in order to decrease the chances of auditors denying your report, avoid them at all costs. Look at the two codes below:

• S46.00 (Unspecified injury of muscle[s] and tendon[s] of the rotator cuff of shoulder)
• S46.09 (Other injury of muscle[s] and tendon[s] of the rotator cuff of shoulder)

The ambiguity of these definitions makes it difficult to pinpoint exactly what needs to be charged. Whenever possible, use your know-how of orthopedic vocabulary and your knowledge of trauma levels to accurately identify the correct code.