Bicipital tendinitis, unspecified shoulder

This code signifies inflammation of the biceps tendon in the shoulder, without further specification of laterality (left or right). It indicates a general diagnosis of bicipital tendinitis where the specific affected shoulder is not documented.

Apply this code when the medical record clearly states "bicipital tendinitis" but does not specify whether it affects the left or right shoulder. Documentation supporting its use includes physician notes describing shoulder pain, tenderness over the bicipital groove, and positive Speed's or Yergason's tests, without laterality.

• Avoid using this code if laterality (left or right shoulder) is documented; instead, choose the more specific M75.21 (right) or M75.22 (left).
• Ensure the documentation supports tendinitis and not a rupture or other bicep pathology.
• Consider sequencing this code as a primary diagnosis if it is the main reason for the encounter.