Spontaneous rupture of flexor tendons, right shoulder
ICD-10 M66.311 is a billable code used to indicate a diagnosis of spontaneous rupture of flexor tendons, right shoulder.
Spontaneous rupture of flexor tendons in the right shoulder is a condition characterized by the unexpected tearing of the flexor tendons, which are responsible for the movement and stability of the shoulder joint. This condition can occur without any preceding trauma or injury, often linked to underlying degenerative changes or inflammatory processes such as tenosynovitis. Patients may present with acute pain, swelling, and loss of function in the shoulder, which can significantly impact daily activities. Diagnosis typically involves a thorough clinical examination, imaging studies such as MRI or ultrasound, and assessment of the patient's history. Treatment options may include conservative management with physical therapy and anti-inflammatory medications, or surgical intervention to repair the ruptured tendons, depending on the severity of the rupture and the patient's overall health. Accurate coding of this condition is crucial for appropriate reimbursement and to reflect the complexity of the patient's clinical picture.
Detailed operative reports, imaging studies, and pre-operative assessments.
Surgical repair of ruptured tendons, post-operative follow-up for tendon healing.
Ensure documentation reflects the surgical approach and any complications.
Comprehensive evaluations, treatment plans, and progress notes.
Rehabilitation post tendon repair, management of pain and function.
Document functional limitations and response to therapy.
Used when surgical repair is performed for spontaneous rupture.
Operative report detailing the procedure and findings.
Orthopedic documentation must include pre-operative assessments and post-operative care plans.
Spontaneous tendon rupture occurs without any identifiable trauma, often due to degenerative changes, while traumatic rupture is a direct result of an injury or accident.
