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Rotator Cuff Tear - If a patient has an accident

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kellit21

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Boiling Springs, SC
If a patient has an accident and tears the rotator cuff, but it isn't a full thickness tear do you still code with the S43.42_ code or do you go with the incomplete tear which is listed as non traumatic?
 
The provider must be the one to clarify this in the chart note. However if you look in the codebook.. Category S43 is dislocation of joints and ligaments, and S46 is injury to muscle fascia and tendons. An individual code is an extension of the category. Ifyou have enough documentation to go on you might be able to figure it out.
 
Last edited:
"Traumatic" partial thickness tear of the Rotator Cuff

Whether the tear is "partial" or "complete" from the accident/trauma is not really relevant to this patient's diagnosis code. It is a traumatic injury to a tendon of the shoulder, so would have to be in the S46 Code Set, S46.0 _ _, Injury to the muscles and/or tendons of the rotator cuff. The exact mechanism of the injury is not described, so you do not know whether it was a "Strain" or "Other." For it to be a "Laceration" would require an open wound, which there does not seem to be. Therefore, I would go with S46.09 _ A (6th character for laterality).

Respectfully submitted, Alan Pechacek, M.D.
 
S code vs. M code

What section would I code from in this situation?
A patient tore his rotator cuff 7 months ago due to an injury. It has never healed properly and he seeks treatment for it today. Would I use S code because it is due to an injury, or would I use an M code because it and older injury? I understand the index states that chronic conditions are coded to Chapter 13, but what makes the injury chronic? The doctors statement? The mention of how much time has passed? At what point do the S injury codes turn to M codes?:confused:
 
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