Unsp rotatr-cuff tear/ruptr of left shoulder, not trauma

This code signifies a tear or rupture of the rotator cuff in the patient's left shoulder, where the specific cause (e.g., acute injury vs. degenerative) is not documented. It indicates damage to one or more of the four muscles and their tendons that stabilize the shoulder joint. The "unspecified" nature means the provider has not determined or documented whether the tear was due to a specific traumatic event or a gradual degenerative process.

Use this code when documentation clearly states a rotator cuff tear of the left shoulder but lacks specificity regarding its traumatic or non-traumatic origin. This is appropriate when the provider's assessment or imaging reports confirm a tear but do not elaborate on the etiology. Supporting documentation would include imaging reports (MRI, ultrasound) confirming a tear and physician notes indicating the left shoulder as the affected side without further detail on the cause.

• Avoid using this code if documentation specifies a traumatic event (e.g., fall, direct blow); instead, look for codes in the S46 series.
• Do not use if the tear is explicitly documented as non-traumatic or degenerative; refer to M75.122.
• Always query the provider for clarification on the etiology (traumatic vs. non-traumatic) to allow for more specific coding when possible.