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v1.0.0
ICD-10 Guide
ICD-10 CodesM21.211

M21.211

Billable

Flexion deformity, right shoulder

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/17/2025

Code Description

ICD-10 M21.211 is a billable code used to indicate a diagnosis of flexion deformity, right shoulder.

Key Diagnostic Point:

Flexion deformity of the right shoulder refers to a condition where the shoulder joint is unable to extend fully due to a fixed flexed position. This deformity can arise from various acquired causes, including trauma, neurological conditions, or prolonged immobilization. Patients may present with limited range of motion, pain, and functional impairment, impacting daily activities. The condition can be associated with other deformities, such as contractures or muscle imbalances, and may require a multidisciplinary approach for management. Treatment options often include physical therapy, surgical interventions, or corrective procedures aimed at restoring function and alleviating discomfort. Understanding the underlying cause is crucial for effective treatment and rehabilitation, as well as for accurate coding and documentation.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between acquired and congenital deformities
  • Identifying the underlying cause of the flexion deformity
  • Documenting associated conditions or comorbidities
  • Understanding the impact on functional status and daily activities

Audit Risk Factors

  • Inadequate documentation of the cause of the deformity
  • Failure to document associated conditions
  • Lack of clarity on the functional impact of the deformity
  • Inconsistent coding of related procedures

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed notes on the patient's history, physical examination findings, and imaging results.

Common Clinical Scenarios

Patients with post-traumatic shoulder flexion deformities or those with neurological conditions affecting shoulder mobility.

Billing Considerations

Ensure to document the degree of deformity and any associated functional limitations.

Physical Medicine and Rehabilitation

Documentation Requirements

Comprehensive assessment of functional status and rehabilitation goals.

Common Clinical Scenarios

Patients undergoing rehabilitation for shoulder flexion deformities post-surgery or injury.

Billing Considerations

Focus on documenting the patient's progress and response to therapy.

Coding Guidelines

Inclusion Criteria

Use M21.211 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of the condition's acquired nature
  • Include any relevant comorbidities and the impact on the patient's daily life
  • Ensure that the code is supported by clinical documentation

Exclusion Criteria

Do NOT use M21.211 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

23470CPT Code

Shoulder arthroscopy

Clinical Scenario

Used for surgical correction of shoulder deformities.

Documentation Requirements

Detailed operative notes and pre-operative assessments.

Specialty Considerations

Orthopedic surgeons should document the rationale for surgery.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like flexion deformities, improving the accuracy of patient records and facilitating better treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like flexion deformities, improving the accuracy of patient records and facilitating better treatment planning.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like flexion deformities, improving the accuracy of patient records and facilitating better treatment planning.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the primary cause of flexion deformity in the shoulder?

Flexion deformity can result from various factors, including trauma, neurological conditions, or prolonged immobilization, leading to muscle imbalances and joint contractures.