Right shoulder pain ICD 10 code
Right shoulder pain ICD 10 code is a billing code that most physical therapists will become familiar with because of the prevalence of shoulder pain. Shoulder pain is the result from a number of conditions, significantly impacting function of the upper extremities and is often treated in physical therapy clinics. Along with neck and back pain, shoulder pain is one of the most commonly treated orthopedic conditions.
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Both intra and extra articular sources of pain are possible as are acute, subacute and chronic forms of pain. Identification of the source of pain is helpful in selecting the appropriate treatment interventions, informing prognosis for recovery and determining when referral to a higher level of care, such as a physician or surgeon, is necessary.
The shoulder is a complex anatomical structure consisting of many muscles, tendons, bursa, bones, ligaments, joint capsules, nerves and cartilage. The glenohumeral joint and acromioclavicular joint may be involved in shoulder pain as can the structures of the cervical spine, in the case of radicular pain patterns. When patients complain of pain in the shoulder it is important to screen for other signs and symptoms that may indicate a potential source of their discomfort.
Some of these signs and symptoms include:
- Sharp, dull, aching, burning or electric pain
- Numbness and tingling in the neck, shoulder, arm or hand
- Weakness around the shoulder and distally
- Stiffness or loss of shoulder range of motion
- Pain at rest vs pain with movement
- Neck pain or stiffness
As you can see, identifying the cause of shoulder pain requires taking into account numerous structures in the area.
When a patient presents with shoulder pain and without a definitive diagnosis, there are several options for trying to accurately identify the source of pain:
- Special tests of the upper quarter
- Cervical spine assessment and provocation tests to rule out cervical radiculopathy
- Shoulder special tests such as:
- Neer’s impingement test
- Apprehension test for shoulder instability
- Active compression/O’brien’s Test for AC Joint
- Hawkins/Kennedy Impingement Test
- Empty/Full Can test for supraspinatus
- Lift Off Test for subscapularis
- Speed’s Test for biceps tendinopathy or superior labral tear
- X-ray to visualize bone and joint integrity
- CT Scan or MRI to visualize bone and soft tissue structures
- Ultrasound
Be sure to review your red flags for this area in order to refer to the appropriate provider when present.
Because of its prevalence, you will likely encounter this condition frequently in your practice and understanding how to correctly utilize the right shoulder pain ICD 10 code is imperative for minimizing insurance claim denials. If you, like many therapists, have some experience searching for and selecting ICD-10 codes like the right shoulder pain ICD 10 code but don’t have a good understanding of the who, what, when and why these codes are used. See the next section for an ICD-10 code primer. Following this introduction we will discuss the shoulder pain right shoulder pain ICD 10 code in more detail.
An introduction to ICD-10 Codes and the right shoulder pain ICD 10 code
Who: All HIPAA-covered entities are required to submit ICD-10 codes if seeking reimbursement for services from an insurance company. This includes physical therapists.
What: The International Classification of Disease, 10th Revision (ICD-10) is a set of diagnosis, symptom, and procedure codes that physical therapists use daily in their practice. ICD-10 codes are alphanumeric codes. They begin with a letter and are always between three and seven characters with a decimal point placed after the third character. The more characters it has, the more specific it is.
Each code follows the following structure:
- Characters 1-3 indicate the category of the diagnosis
- Characters 4-6 indicate etiology, anatomic site, severity or other clinical detail
- Character 7 is an extension value, for example:
- A: initial encounter (anything related to care of the initial injury)
- D: subsequent encounter (anything related to the phase of routine care of the injury while the patient recovers–this usually refers to rehabilitation)
- S: sequela (other conditions that may result from the presence of the primary condition)
Note, for fracture care, there are several more extensions (example: P, G, K, which signify malunion, delayed healing, or nonunion for a subsequent encounter)
When: ICD-10 codes must be submitted with relevant documentation whenever reimbursement is sought for covered services either by the healthcare entity itself or by a patient.
Why: While it may seem like an extra step in an already detailed process of documentation and billing, ICD-10 codes are required for a specific reason. Not only do they identify a medical diagnosis, but perhaps more importantly, they help insurance companies understand why the care you are providing is medically necessary and therefore, reimbursable.
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Right shoulder pain ICD 10 code: M25.511
M25.511 Pain in right shoulder
This right shoulder pain ICD 10 code is used in situations where the patient is presenting with discomfort or pain in the shoulder region lasting more than 3 months (chronic) or less than 3 months (acute). It can be used to account for both shoulder and AC joint pain. This code is considered specific enough for billing/reimbursement purposes but alternative codes may be available that more accurately describe your patient’s condition. For example, there are specific codes for medical conditions and injuries such as AC joint sprain (S43.5) or lesion of the superior glenoid labrum, right shoulder (S43.43.431) which may also be included in addition to the code describing patient symptoms of shoulder pain.
When it comes to selecting right shoulder pain ICD 10 code, the Centers for Medicare and Medicaid Services publish an updated list of codes each year to go into effect October 1 and remain in effect until September 30 of the following year. Sites like ICD10 Data can also be helpful in identifying code changes once they update their list as announced on their homepage.
Treatment and billing
Creating a treatment plan and selecting appropriate billing codes like the right shoulder pain ICD 10 code are also essential components of thorough documentation and increase the likelihood of insurance reimbursement for PT services. When it comes to creating a treatment plan it is important to be familiar with the patient’s underlying condition so you can select evidence-based treatment interventions as well as have an idea of the timeline for recovery.
Here are some tips for billing and documentation for right shoulder pain:
- Select appropriate subjective and objective outcome measures to assess patient presentation, symptoms and functional impairments
- Create timely, measurable and specific goals
- Reassess at regular intervals to determine the effectiveness and modify as needed, the plan of care
- Report accurate CPT codes based on the treatment or assessment you provided
While successfully treating a patient with right shoulder pain may require a lot of hard work on your part, managing the billing, coding, patient scheduling and documentation doesn’t need to be.
Resources
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More resources
- Physical therapy ICD 10 codes
- Physical therapy CPT codes
- Therapy resources and worksheets
- Therapy private practice courses
- Ultimate teletherapy ebook
- The Ultimate Insurance Billing Guide for Therapists
- The Ultimate Guide to Starting a Private Therapy Practice
