Spontaneous rupture of extensor tendons, shoulder
ICD-10 M66.21 is a billable code used to indicate a diagnosis of spontaneous rupture of extensor tendons, shoulder.
Spontaneous rupture of extensor tendons in the shoulder is a condition characterized by the unexpected tearing of the extensor tendons, which are responsible for extending the arm and fingers. This condition can occur without any significant trauma or injury, often associated with underlying degenerative changes or inflammatory processes. Patients may present with sudden pain, swelling, and loss of function in the shoulder area. The rupture can lead to significant impairment in daily activities, particularly those requiring arm extension. Diagnosis typically involves a thorough clinical examination, imaging studies such as MRI or ultrasound, and sometimes arthroscopy to confirm the extent of the injury. Treatment options may include conservative management with physical therapy and anti-inflammatory medications, or surgical intervention to repair the ruptured tendon, depending on the severity of the rupture and the patient's functional needs. Accurate coding is essential for proper reimbursement and to reflect the complexity of the condition.
Detailed operative reports, imaging results, and post-operative care notes.
Patients presenting with acute shoulder pain and loss of function, often after minor trauma or spontaneously.
Ensure documentation reflects the specific tendon involved and the surgical technique used for repair.
Comprehensive assessment of functional limitations and rehabilitation progress notes.
Patients undergoing rehabilitation post-surgery for tendon repair or those managed conservatively.
Document functional outcomes and any co-morbid conditions affecting recovery.
Used when surgical repair of the extensor tendon is performed.
Operative report detailing the procedure and findings.
Orthopedic surgeons must document the specific tendon repaired and the surgical technique used.
Common causes include degenerative changes due to aging, chronic inflammatory conditions, and overuse injuries. Patients may also have underlying systemic diseases that weaken tendon integrity.
