Spontaneous rupture of extensor tendons, left shoulder
ICD-10 M66.212 is a billable code used to indicate a diagnosis of spontaneous rupture of extensor tendons, left shoulder.
Spontaneous rupture of extensor tendons in the left shoulder is a condition characterized by the unexpected tearing of the extensor tendons, which are responsible for extending the fingers and wrist. This condition can occur without any significant trauma or injury, often associated with underlying degenerative changes or inflammatory processes such as tenosynovitis. Patients may present with sudden pain, swelling, and loss of function in the affected shoulder. The diagnosis is typically confirmed through clinical examination and imaging studies, such as MRI, which can reveal tendon integrity and associated soft tissue changes. Treatment options may include conservative management with rest and physical therapy 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 and its management.
Detailed notes on the mechanism of injury, physical examination findings, imaging results, and treatment plan.
Patients presenting with sudden shoulder pain and loss of function, often after minimal or no trauma.
Ensure that the documentation clearly states the spontaneous nature of the rupture and any associated conditions.
Comprehensive assessment of functional limitations and rehabilitation goals.
Patients requiring rehabilitation post-surgery or those managing symptoms conservatively.
Document the patient's progress and response to therapy to support ongoing treatment.
Used when surgical repair is performed for the spontaneous rupture.
Operative report detailing the procedure and findings.
Orthopedic surgeons must document the nature of the rupture and any associated findings.
Spontaneous tendon rupture occurs without significant trauma, often due to underlying conditions, while traumatic rupture results from a specific injury or event.
