Postimmunization arthropathy, unspecified shoulder
ICD-10 M02.219 is a billable code used to indicate a diagnosis of postimmunization arthropathy, unspecified shoulder.
Postimmunization arthropathy refers to joint pain and inflammation that occurs following vaccination, specifically affecting the shoulder joint in this case. The shoulder is a complex joint comprised of the humerus, scapula, and clavicle, with a range of motion facilitated by muscles, tendons, and ligaments. The pathophysiology involves an immune-mediated response where the body reacts to the vaccine components, leading to synovitis and pain in the shoulder region. Clinically, patients may present with localized pain, swelling, and reduced range of motion, often exacerbated by movement. The condition can mimic other shoulder pathologies, making accurate diagnosis essential. Treatment typically involves conservative management such as NSAIDs, physical therapy, and in some cases, corticosteroid injections to alleviate inflammation and restore function.
Orthopedic documentation should include imaging studies (e.g., X-rays, MRIs) to assess joint integrity and functional assessments to evaluate range of motion.
Patients presenting with shoulder pain post-vaccination may require surgical intervention if conservative measures fail, necessitating detailed surgical documentation.
Joint-specific considerations include assessing for rotator cuff involvement and the severity of inflammation.
Rheumatologic documentation should include laboratory tests for inflammation markers (e.g., ESR, CRP) and assessments of disease activity.
Patients may present with systemic symptoms alongside localized shoulder pain, requiring a comprehensive evaluation of autoimmune conditions.
Consideration of systemic involvement and monitoring for potential progression of rheumatologic diseases is crucial.
Functional assessments should detail mobility limitations and rehabilitation needs, including range of motion tests and strength evaluations.
Rehabilitation scenarios may involve physical therapy to restore function and mobility post-vaccination.
Assessment of assistive device needs and patient education on joint protection strategies are important.
Used for corticosteroid injection in cases of severe inflammation post-vaccination.
Documentation must include indication for the procedure, joint involved, and any imaging guidance used.
Orthopedic considerations include assessing joint stability and the need for further intervention.
Common symptoms include localized shoulder pain, swelling, stiffness, and reduced range of motion, typically occurring within days to weeks following vaccination.
Coders should look for a clear temporal relationship between vaccination and symptom onset, along with documentation of exclusion of other shoulder pathologies through imaging and clinical evaluation.
