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

This code signifies a full-thickness tear or rupture of one or more tendons of the rotator cuff in the patient's left shoulder. The tear extends completely through the tendon, but the etiology is not explicitly documented as traumatic. This condition typically results in significant pain and functional impairment of the shoulder.

Apply this code when documentation clearly indicates a complete rotator cuff tear of the left shoulder, and the provider does not specify the injury as acute or traumatic. This is appropriate for degenerative tears or when the mechanism of injury is not clearly defined as traumatic. Supporting documentation includes MRI reports, surgical notes, and physician's notes detailing the tear's completeness and laterality.

• Ensure the documentation specifies "complete" or "full-thickness" to differentiate from partial tears (M75.11-).
• Verify laterality; this code is specifically for the left shoulder.
• Only use this code when trauma is not documented as the cause; otherwise, refer to the traumatic rotator cuff tear codes (S46.01-).