Complete rotatr-cuff tear/ruptr of unsp shoulder, not trauma

This code signifies a full-thickness tear or rupture of one or more tendons comprising the rotator cuff in the shoulder, where the specific shoulder (left or right) is not documented. It applies to tears that are degenerative or chronic in nature, rather than those resulting from an acute injury.

Use this code when documentation clearly indicates a complete rotator cuff tear but does not specify laterality (e.g., "complete rotator cuff tear"). This code is appropriate when the tear is explicitly stated as non-traumatic, chronic, or degenerative, or when no mention of trauma is present.

• Always seek clarification from the provider if laterality is not documented for a complete rotator cuff tear.
• Do not use this code if the documentation specifies the tear as traumatic; instead, refer to codes in the S46.0-S46.2 series.
• If the tear is partial, use codes from the M75.10-M75.11 series.