Rotator cuff coding clarification

ROTATOR CUFF TEAR Date: BWC 11/2019

Issue When an injured worker’s injury is a traumatic rotator cuff tear the ICD-10 code and corresponding description map to sprain, strain, and tear of the rotator cuff ligament/muscle/tendon. Confusion occurs when it is appropriate to add an allowance, or how to appropriately reflect the injury description for the allowance.

Purpose To clarify the code assignment and associated injury description for a sprain, strain, and tear of the rotator cuff ligament/ muscle/tendon and to provide guidance regarding an additional allowance when the initial injury was described as a sprain or a strain instead of a tear.

Definition A traumatic rotator cuff diagnosis is defined as an injury of the rotator cuff ligaments, muscles, and tendons and maps to rotator cuff sprain/strain and/or tear/rupture. ICD-10 codes S46.011A (right shoulder) and S46.012A (left shoulder) are for strain/tear/rupture OR S43.421A (right shoulder) and S43.422A (left shoulder) are for sprain/tear/rupture.

A non-traumatic rotator cuff injury diagnosis is assigned when the injury to the rotator cuff was pre-existing and the injured worker substantially aggravated the pre-existing condition as a result of the work-related injury. This is assigned to M75.1* category ICD-10 codes based on the severity of the tear (incomplete vs. complete).

Clarification When a traumatic injury involves a sprain, strain or tear of the muscles or tendons of the rotator cuff of the shoulder, the provider will document the nature and description of the injury fully in the medical notes. BWC uses this description to identify the allowance.

If the provider initially diagnoses and requests an allowance of a sprain of the rotator cuff capsule/ligament or strain of the rotator cuff muscles/tendons and future diagnostic testing identifies a tear, BWC will consider an additional allowance request for the tear even though the two conditions – sprain and tear, or strain and tear map to the same ICD-10 code (see the mapping algorithm and table for the rotator cuff injury).

Examples: 1. The IW has a shoulder injury. The physician orders an MRI and the MRI shows a tear. The physician documents the injury diagnosis as a rotator cuff (supraspinatus) tear of the right shoulder. The physician, in the electronic medical record (EMR) appropriately selects ICD-10 code S46.011A. Because the ICD-10 code book reflects the industry description, the EMR printout of the medical documentation may state “strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder”. Even though the formal industry description of S46.011A doesn’t include “tear”, it is a part of this ICD code due to mapping (see the mapping algorithm). Since the physician has documented a rotator cuff tear and has supporting medical documentation (MRI), BWC will base the injury description on the rotator cuff tear and BWC’s claim allowance would be modified to reflect the tear.

2. The IW has a shoulder injury, however, in this example, the physician initially limits documentation to a strain of the right rotator cuff. The claim allowance of S46.011A and description of strain of the right rotator cuff is added. A few months later, the IW continues to have pain and after an MRI, the physician diagnoses a rotator cuff tear. Because the ICD-10 code for strain and tear map to the same ICD code, the physician would not choose a different ICD-10 code in the EMR. To avoid the confusion regarding future medical treatment, the physician may submit a request for an additional allowance with the medical justification of the MRI. When allowed, BWC would add a second claim allowance, both with the same ICD-10 code, but with different descriptions as follows: S46.011A: Strain of right rotator cuff S46.011A: Right rotator cuff tear

November 2019 Coding Assignment Mapping Algorithm:

Rotator cuff tear/rupture

Assign M75.1* category code (non- traumatic/degenerative tear)

Complete tear – M75.121 (right) or M75.112 (left) Is the rotator cuff tear NO due to injury Incomplete tear – M75.111 (right) or (traumatic)? M75.112 (left) Unspecified tear – M75.101 (right) or M75.102 (left)

YES

Is the rotator cuff tear involving ligament OR muscle/tendon?

Ligament Muscle/tendon tear/rupture tear/rupture

Rotator cuff muscle/tendon tear Rotator cuff ligament tear— (infraspinatus, supraspinatus, S43.421A (right) or subscapularis, and minor teres) – S43.422A (left) S46.011A (right) or S46.012A (left)

Table for the rotator cuff injuries

Injury description ICD-10 Code CMS ICD code description

Rotator cuff sprain S43.421A (right shoulder) Sprain of right (left) rotator cuff capsule S43.422A (left shoulder)

Rotator cuff capsule (ligament) tear S43.421A (right shoulder) Sprain of right (left) rotator cuff capsule S43.422A (left shoulder)

Rotator cuff strain S46.011A (right shoulder) strain of muscle(s) and tendon(s) of the S46.012A (left shoulder) rotator cuff of right (left) shoulder

Rotator cuff muscles/tendons tear S46.011A (right shoulder) strain of muscle(s) and tendon(s) of the (includes supraspinatus, infraspina- S46.012A (left shoulder) rotator cuff of right (left) shoulder tus, subscapularis, and minor teres)

November 2019