Consider these various factors when coding disorders of the shoulder joint.
Most seasoned radiology coders have learned to view each joint of the body as its own separate entity. Very rarely will you find anatomical consistencies between any given pair of joints. It's for that reason that the coding of joint pathologies tends to be one of the final frontiers coders have to overcome on their way to considering themselves experts.
For many, coding of the pathologies of the shoulder has led to plenty of instances of blank stares and head scratches - and understandably so. There are numerous factors to consider when making a determination on the correct diagnosis code for a particular disorder of the shoulder. However, as you will see, as long as you can accurately interpret the indication, impression, and underlying source of the disorder, coding shoulder diagnoses isn't as painful as its made out to be.
Dive into this example to get you well on your way to becoming a shoulder pathology coding expert.
Begin Your Analysis with Indicating Diagnoses
Indication: Work-related injury. Assess for traumatic tear left rotator cuff with superior shoulder pain and weakness.
Impression: There is mild supraspinatus tendinosis with minimal articular sided fraying of the distal tendon and a 3-mm low-grade interstitial tear at the distal attachment site.
In your approach to finding the right diagnosis code, you first need to identify which diagnoses from the impression should and should not be coded. While making this determination can be subjective, there are certain instances when you should leave out particular diagnoses due to the nature of the indicating diagnoses.
Based on the indication, you are looking for any diagnoses that may be a result of a shoulder injury. If it is not determinable as to whether a diagnosis from the impression is the possible result of an injury, you should include the diagnosis. If the indication had only stated "Assess for traumatic tear left rotator cuff," then you would not include any additional diagnoses referenced in the impression (assuming the impression identified a definitive rotator cuff tear). However, in this case, the additional phrasing of "with superior shoulder pain and weakness" leaves the range of diagnostic considerations somewhat open-ended.
Since the phrasing in the indication allows for possible diagnoses beyond just a rotator cuff tear, you now have to take a look at the other diagnoses in the impression to determine whether they may be the result of an injury. If, for example, there was a diagnosis of "degenerative arthritis of the acromioclavicular (AC) joint," then you would immediately know not to include that diagnosis code. However, the diagnoses of "tendinosis" and "articular-sided fraying" of the supraspinatus tendon are less clear as to whether or not you should include them as separate diagnoses from the rotator cuff tear.
Compare and Contrast Indication with Impression
In order to definitively decide, you need to take a look at the rotator cuff tear diagnosis along with a few additional considerations. You know that the impression states "a 3-mm low-grade interstitial tear at the distal attachment site." "Since this diagnosis is not definitively linked to the supraspinatus tendon, you will want to refer back to the body of the report to make sure the tear documented in the impression is, in fact, that of the supraspinatus tendon," explains Barry Rosenberg, MD, chief of radiology at United Memorial Medical Center in Batavia, New York.
Assuming that you confirm that the tear is linked to the distal supraspinatus tendon, your window of possible diagnosis codes becomes much clearer. However, this moment of clarity can only occur if you have a strong fundamental knowledge of the anatomy of the shoulder and how certain diagnoses can play off of one another.
While an inexperienced coder may consider "fraying" of the tendon to be a separate injury, or even pathologically unrelated to the injury entirely, consider this quote from the American Academy of Orthopedic Surgeons (AAOS):
This information, coupled with the definitive rotator cuff tear at the same anatomical site as the fraying, leads you to the conclusion that you should not include a diagnosis code for "fraying" of the supraspinatus tendon.
Similarly, the AAOS defines tendinosis as, simply, "a swelling of the tendons." Clearly, a diagnosis as severe as a traumatic rotator cuff tear can result in tendinosis of the torn tendon. Therefore, you should not consider tendinosis a valid diagnosis for this claim, either.
Combine Knowledge for Final Verdict
After all is said and done, the only diagnosis code you will be considering is the diagnosis of a traumatic tear of the rotator cuff. Despite the fact that the impression does not state "rotator cuff," you should know that the supraspinatus tendon is a part of the rotator cuff.
Additionally, you will be lead to the wrong diagnosis code by searching for Tear ⇒ supraspinatus. When assigning a code for a rotator cuff tear, you must make sure you do not assign a nontraumatic tear code for a tear that is the result of a shoulder injury. By searching for Tear ⇒ supraspinatus or Tear ⇒ rotator cuff, you will be assigned code M75.10X (Unspecified rotator cuff tear or rupture, not specified as traumatic), which is incorrect based on the indication of a work-related injury.
Instead, you want to search under Injury ⇒ muscle (and fascia) (and tendon) ⇒ rotator cuff (muscle(s)) (tendon(s)) ⇒ strain. You have the option to choose between strain, laceration, and other specified. Some might assume that a tear and a laceration are one in the same; however, you should never code a laceration unless the provider documents it. On the other hand, a tear of a tendon is considered to be a high-level strain. Therefore, you should code an initial encounter for a traumatic tear of the left supraspinatus tendon as S46.012A (Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter).