ICD-10 Coding for Bilateral Shoulder Pain(M19.011, M19.011B, M19.011P)
Learn about the ICD-10 coding for bilateral shoulder pain, including specific codes for right and left shoulder pain, and documentation requirements.
Complete code families applicable to Bilateral Shoulder Pain
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M25.51 | Pain in right shoulder | Use when pain is specifically localized to the right shoulder. |
|
| M25.52 | Pain in left shoulder | Use when pain is specifically localized to the left shoulder. |
|
| M75.43 | Bursitis of bilateral shoulders | Use when bursitis is confirmed in both shoulders. |
|
| M19.011 | Primary osteoarthritis, right shoulder | Use when osteoarthritis is confirmed in the right shoulder. |
|
| M19.012 | Primary osteoarthritis, left shoulder | Use when osteoarthritis is confirmed in the left shoulder. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information
Essential facts and insights aboutBilateral Shoulder Pain
Alternative codes to consider when ruling out similar conditions
Use when pain is specifically localized to the left shoulder.
Use when pain is specifically localized to the right shoulder.
Use when osteoarthritis is confirmed in the left shoulder.
Use when osteoarthritis is confirmed in the right shoulder.
Documentation & Coding Risks
Avoid these common issues when documenting Bilateral Shoulder Pain.
Failing to document laterality of shoulder pain.
Impact
Clinical: Leads to inaccurate diagnosis and treatment., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation
Always document laterality in clinical notes.
Using unspecified codes when laterality is known.
Impact
Reimbursement: May result in claim denials or reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation
Document and code for specific laterality (right, left, bilateral).
Laterality documentation
Impact
Failure to document laterality can lead to audit findings.
Mitigation
Implement checklist for documentation to ensure laterality is recorded.