ICD Code M25.51

ICD code M25.51 is used to classify and document instances of pain located specifically in the shoulder. This code helps healthcare providers accurately record and communicate the diagnosis of shoulder pain for purposes such as treatment planning, billing, and statistical analysis.

1. Localized Pain: The patient reports pain specifically in the shoulder region, without radiating to other areas such as the neck or arm.

2. Onset and Duration: The pain may be acute or chronic, with a clear onset that can be sudden or gradual over time.

3. Pain Characteristics: The pain can be described as sharp, dull, aching, or throbbing, and may vary in intensity from mild to severe.

4. Impact on Mobility: The pain affects the patient's ability to move the shoulder, potentially limiting range of motion or causing discomfort during movement.

5. Exacerbating Factors: Activities such as lifting, reaching, or overhead movements exacerbate the pain, indicating a link to shoulder function.

6. Alleviating Factors: Rest, ice, heat, or over-the-counter pain medications may provide temporary relief, suggesting a musculoskeletal origin.

7. Associated Symptoms: There may be accompanying symptoms such as swelling, tenderness, or warmth around the shoulder joint.

8. Absence of Systemic Symptoms: The patient does not exhibit systemic symptoms such as fever, weight loss, or night sweats, which could indicate a more serious underlying condition.

9. Exclusion of Other Causes: Other potential causes of shoulder pain, such as fractures, dislocations, or systemic diseases, have been ruled out through clinical evaluation and diagnostic testing.

10. Clinical Evaluation: A healthcare provider has conducted a thorough physical examination and possibly imaging studies to confirm the diagnosis of shoulder pain.

For the ICD code M25.51 (Pain in shoulder), the relevant CPT codes that may be applicable for treatment include:

1. 20610 - Arthrocentesis, aspiration, and/or injection into a major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa); without ultrasound guidance.

2. 20611 - Arthrocentesis, aspiration, and/or injection into a major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.

3. 23130 - Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release.

4. 23410 - Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; acute.

5. 23412 - Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; chronic.

6. 29806 - Arthroscopy, shoulder, surgical; capsulorrhaphy.

7. 29807 - Arthroscopy, shoulder, surgical; repair of SLAP lesion.

8. 29826 - Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with or without coracoacromial release.

9. 97110 - Therapeutic exercises to develop strength and endurance, range of motion, and flexibility (each 15 minutes).

10. 97140 - Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes.

These CPT codes are examples of procedures and treatments that may be considered for addressing shoulder pain associated with ICD code M25.51. The selection of specific CPT codes should be based on the individual patient's condition and the healthcare provider's clinical judgment.

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