ICD Code M75.111

ICD code M75.111 is an incomplete tear or rupture of the rotator cuff in the right shoulder, and it is not specified as being caused by trauma.

1. Patient presents with shoulder pain localized to the right side.

2. Clinical examination reveals weakness or limited range of motion in the right shoulder.

3. Imaging studies (such as MRI or ultrasound) confirm a partial-thickness tear or incomplete rupture of the rotator cuff in the right shoulder.

4. No evidence or documentation of acute trauma as the cause of the tear.

5. Symptoms may include difficulty lifting the arm, pain with overhead activities, and night pain affecting sleep.

6. Physical findings may include tenderness over the rotator cuff, positive impingement signs, and decreased strength in abduction or external rotation.

Relevant CPT codes for ICD-10 code M75.111 include:

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

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

- 23420: Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

- 29827: Arthroscopy, shoulder, surgical; with rotator cuff repair

- 29822: Arthroscopy, shoulder, surgical; debridement, limited

- 29823: Arthroscopy, shoulder, surgical; debridement, extensive

These CPT codes may be used in conjunction with ICD-10 code M75.111, depending on the clinical scenario and procedure performed.

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