Shoulder¶

· Entry of treatment code ‘Other repair of shoulder including acromioplasty or subacromial depression’ includes removal of a part/portion of the acromion

· The acromion is the top or upper portion of the shoulder blade (scapula)

· The ICD10 Root Code for this is 0RQH

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Bankhart Lesion/Bankhart Tear¶

· Involves the labrum and is a tear of the anterior labrum; in the system the SLAP injury code is used for these

· A Bankhart Lesion/Tear is often associated with an anterior shoulder dislocation (where the humerus detaches from the glenoid cavity); if this is the case enter both the SLAP and the shoulder dislocation codes

· The ICD10 Root Code for this is S43.43

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Clavicle resection (Mumford Procedure, Claviculectomy) { #Clavicle_resection(Mumford }¶

· Shoulder surgery often includes a resection of a piece of the clavicle. Often this procedure is referred to as ‘resection of distal clavicle’, ‘partial claviculectomy’ or ‘partial resection of the clavicle’; it is also sometimes referred to as a Mumford Procedure

· A ‘claviculectomy’ is an excision of the clavicle. Typically, it is a partial excision which involves the distal portion of the clavicle

· The ICD10 Root Code for a claviculectomy is 0PB9 or 0PBB

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Coracoacrominal Ligament Release partial or full¶

· The ICD10 Root Code for this is 0L82

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Debridement of Labrum

Much like a rotator cuff tear, a tear of the labrum does not always require a repair. Frequently torn /frayed edges can be removed or debrided.
In the system, debridement of the labrum is entered as 'Other local excision or destruction of lesion-shou8lder'
The root code for the right shoulder is 0RBJ0ZZ and for the left shoulder is 0RBK0ZZ

Dislocation Shoulder¶

· A shoulder dislocation is where the humerus separates from the glenoid cavity/fossa which is part of the scapula

· The ICD10 root code is S43

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Glenohumeral Dislocation/Shoulder Dislocation { #Myectomy(excision_of }¶

· The ICD10 root code is S43

· Shoulder dislocations can be anterior, posterior or inferior

· Anterior Glenohumeral Dislocation is the most common

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Myectomy (excision of muscle; also used for debridement of muscle) { #Myectomy(excision_of_1 }¶

· A rotator cuff tear does not always require a repair; depending on the severity of the tear a myectomy (a debridement, or shaving away of the damaged/torn portion of the muscle) may be performed

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Rhomboid Strain¶

· The rhomboid muscle is located in the shoulder region

· It attaches to the lower 2/3 of the medial/vertebral border of the scapula to the inferior angle

· A diagnosis of rhomboid strain is entered in the system as a shoulder sprain/strain

· The ICD10 root code for this is S43 or S46

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Rotator Cuff Capsule¶

· The rotator cuff capsule is a separate structure in the shoulder from the rotator cuff muscle

· The capsule covers the shoulder joint

· Rotator cuff capsule is found on Blue Person Search under the injury category of Rotator Cuff Capsule when the shoulder is selected

· Freeform search enter keywords ‘rotator cuff capsule’ as injury type

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Rotator Cuff Muscle Sprain/Strain (Partial tear or tear)¶

· The rotator cuff muscles cover the capsule

· There are four rotator cuff muscles : supraspinatus; infraspinatus; subscapularis ; and teres minor. Enter the specific muscle involved; MRI reports or x-rays are an excellent source for determining the correct muscle

· If there is a partial or complete tear of a rotator cuff muscle and surgery is done to repair the muscle, then this is, for the purpose of the system, considered a severe sprain/strain

· Freeform search enter the name of muscle injured, severity of sprain (minor, moderate or severe) and left (l) or right (r)

· Blue Person search under the injury category of Sprain/Strain when the shoulder is selected

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Scapulectomy¶

· A Scapulectomy is the surgical removal of the scapula which is the flat, triangular bone located in the back of the shoulder commonly referred to as the shoulder blade

· An ostectomy is the surgical removal of bone so a Scapulectomy is also referred to as an ostectomy of the scapula

· The treatment code can be located in the system via freeform search using the keywords ‘ostectomy scapula’

· The ICD10 root code for this is 0PB9 or 0PBB

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Shoulder Separation or Acromioclavicular Joint/Ligament Separation/AC Separation¶

· Shoulder separation or AC joint separation is an injury to the joint between the scapula and clavicle

· AC refers to the acromioclavicular joint/ligament. The AC joint is the junction of the acromion (the end of the scapula) and clavicle and is held in place by three ligaments. The separation may be diagnosed as an

o Acromioclavicular separation

o Acromioclavicular joint separation

o AC joint separation

· AC Separations are generally graded as minor (Grade I), moderate (Grade II) or severe (Grade III)

· The severe, or Grade III, separation is considered a dislocation as it involves complete separation of the clavicle and scapula

· The minor and moderate acromioclavicular joint/ligament sprain/strain codes are used for a Grade I or II Separation

· The codes available in the system for AC separation can be located via freeform search using the key word ‘acromioclavicular’ or ‘acromio’

· The dislocation code should be used if there is a severe AC separation

· ‘Dislocation shoulder - Acromioclavicular (joint)’ is used for a true dislocation , or complete separation of the clavicle and scapula (Grade/Type III AC Separation)

· The ICD10 root code is S43

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SLAP (Superior Labrum Anterior to Posterior) { #SLAP(Superior_Labrum }¶

· Is a labrum tear - a tear of the superior (top) of the labrum from the front to back

· SLAP is found in the Blue Person Search under the Injury category of Sprain/Strain when the shoulder is selected

· Freeform enter keyword‘SLAP’ as an injury type

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Trapezius Sprain { #Clavicle_resection(Mumford_Procedu }¶

· The trapezius muscle runs from the base of the neck down to the shoulder blade and upper back

· Frequently, a trapezius sprain/strain is diagnosed in conjunction with a cervical sprain/strain

o It may be only necessary to enter the cervical sprain/strain since trapezius is part of the neck

· Each case should be assessed on its own merits along with a complete review of the medical records in order to determine the injury

· If a trapezius sprain is diagnosed, it is entered in the system as 'shoulder-sprain/strain-teres minor or other muscle/tendon'

· The ICD10 root code is S46.81

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Shoulder Medical Codes¶

INJURIES ICD10¶

Labral (Labrum) Tear (also known as Slap Lesion/Bankart Lesion) | S43.431A/ S43.432A

---|--- Shoulder Separation/AC Separation (Rupture)/Knocked-down Shoulder/AC | S43.52XA.A/ S43.51XA.A * Dislocation | · Minor/Grade I/Type I | *S43.52XA.A/ S43.51XA.A * · Moderate/Grade II/Type II | *S43.52XA.B/ S43.51XA.B · Severe/Grade III/Type III | S43.1 S43.1 Shoulder Dislocation (humerus dislocates from scapula) | S43.1 Trapezius sprain/strain (minor, moderate or severe) | S46.01

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COMPLICATIONS | ---|--- Bursitis/Subacromial Bursitis | M75.52.BL/ M75.51.BR Frozen Shoulder/Adhesive Capsulitis | M75.02/ M75.01**** Impingement Syndrome/Shoulder Impingement/Chronic Tendonitis | M75.42/ M75.41 Rotator Cuff Syndrome/Rotator Cuff Disease | M75.51.BR/ M75.52.BL Rotator Cuff Tendonitis/Shoulder Tendonitis/Acute Tendonitis | M75.101/M75.102

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TREATMENTS¶

Acromioclavicular Resection	0PB60ZZ.A2/0PB50ZZ.A2
Arthrectomy/Arthrotomy of Shoulder	0R9J0ZZ.RA/0R9K0ZZ.LA
Arthroplasty/Glenoplasty	0RQK0ZZ.A/0RQJ0ZZ.A
Arthroscopy	0RJK0ZZ/0RJJ0ZZ
Bristow Repair/Bankart Repair/Putti Platt Procedure	0RSK0ZZ.A/0RSJ0ZZ.A
Bursectomy/Removal of Bursa	0MBB0ZZ.C1L/0MB90ZZ.C1R
Debridement of the Labrum	0RBJ0ZZ/0RBK0ZZ
Debridement of Rotator Cuff Muscle(Myectomy)	0RBK0ZZ.B/0RBJ0ZZ.B
Division of Joint Capsule Ligament or Cartilage/Chondrectomy (Removal of Cartilage)	0KB50ZZ.A/ 0KB60ZZ.A
Rotator Cuff Repair/Repair Musculotendinous Cuff	0LQ20ZZ.A/ 0LQ10ZZ.A
Excision of Clavicle/Claviculectomy/Resection Distal Clavicle (Mumford Procedure)	0PB60ZZ.A2/0PB50ZZ.A2
Fusion of Shoulder/Arthrodesis	0RGK0ZZ.G/0RGJ0ZZ.G
Joint Aspiration/Arthrocentesis	0R9K30Z/ 0R9J30Z
Other Repair of Shoulder/Acromioplasty	0RQK0ZZ.G/ 0RQJ0ZZ.G
Scapulectomy	0PB60ZZ.A2/ 0PB50ZZ.A2
Shoulder Replacement (Partial or Complete)/Hemiarthroplasty	0RRK0J6/0RRJ0J6
0RRK0JZ/0RRJ0JZ
SLAP Repair	0RQK0ZZ.G/ 0RQJ0ZZ.G
Subacromial Decompression	0RQK0ZZ.G/ 0RQJ0ZZ.G
Synovectomy	0RBJ/0RBK

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