Eunice Posted Mon 10th of September, 2012 13:54:15 PM
What is correct ICD-9?
Do I use ICD-9: 840.6 or 727.61?
FULL THICKNESS TEAR OF THE SUPRASPINATUS TENDON, WITH RETRACTION OF THE TORN FIBERS TO THE LEVEL OF THE SUPERIOR HUMERAL HEAD, PARTIAL TEAR OF THE UNDERSURFACE OF THE SUBSCAPULARIS TENDON, AND A PARTIAL THICKNESS TEAR OF THE INTRAARTICULAR PORTION OF T
HE BICEPS TENDON
SuperCoder Answered Mon 10th of September, 2012 14:10:50 PM
One is Acute Dx and other Chronic.
Miscoding either one of these scenarios is a fairly common mistake. Typically, 840.4 (Sprains and strains of shoulder and upper arm, rotator cuff [capsule]) should be used for an acute injury, while 727.61 (Complete rupture of rotator cuff) is used to report a chronic condition. The difference is traumatic versus nontraumatic. Sometimes you may find clues based on the patient’s age and whether it was accident- or sportsrelated.
You should look for supporting documentation to determine if the rotator cuff has suffered a traumatic (840.6) versus non-traumatic (727.61) tear, sprain, strain, or rupture. You’ll see the non-traumatic diagnosis more frequently in older patients.
If you can’t find a definitive diagnosis in the documentation -- for example, if the documentation states “rotator cuff syndrome”-- use 726.10 (Disorders of bursae and tendons in shoulder region, unspecified).