Incomplete rotatr-cuff tear/ruptr of l shoulder, not trauma

This code signifies a partial tear or rupture of the rotator cuff tendons in the left shoulder that is not explicitly stated in the medical record as being caused by a traumatic event. This condition often results from degenerative changes, overuse, or chronic impingement, leading to pain and limited range of motion.

Apply this code when documentation specifies an incomplete rotator cuff tear of the left shoulder without any mention of an acute injury or trauma as the cause. This is appropriate for conditions arising from gradual wear and tear or repetitive stress. Supporting documentation would include imaging reports (MRI, ultrasound) confirming a partial tear and physician notes indicating a non-traumatic etiology.

• Ensure the documentation clearly states "incomplete" or "partial" tear; otherwise, a complete tear code may be more appropriate.
• Verify the laterality (left shoulder) is explicitly documented.
• If trauma is documented as the cause, a code from the S46.0- series (Injury of muscle, fascia and tendon of rotator cuff of shoulder) would be more accurate.