correct icd-9 code?

fisherdawnmarie

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Patient has shoulder pain and limted range of motion for 6 months.

The impression reads high-grade rim-rent partial tear of the insertion of the supraspinatus tendon.

Would it be correct to code 840.6?

The icd-9 book directs you to 840.6 based on tear, ligament. I have posted similar questions like this before. Wouldn't you only use this code if the patient had an injury?

Because I am not provided with this information and you are not supposed to assume, wouldn't it be correct to only code the shoulder pain?

Thank you.
 
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Code the tear

If the doctor states the patient has a tear, code the tear, even if he doesn't tell you the method of injury.

F Tessa Bartels, CPC, CPC-E/M
 
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