O14.00 - Mild to moderate pre-eclampsia, unspecified trimester

Clinical Definition

A rotator cuff tendon tear is a disruption in one or more of the four tendons that connect the shoulder muscles to the head of the humerus. Most commonly affects the supraspinatus tendon.

Documentation Requirements

• Laterality: Must specify right, left, or bilateral

• Acuity: Document if acute, chronic, or acute-on-chronic

• Size/Severity: Document as:

  • Partial-thickness

  • Full-thickness

  • Complete/massive

• Traumatic vs. Degenerative: Specify cause if known

• Associated Conditions: Note any:

  • Shoulder impingement

  • Bursitis

  • Biceps involvement

• Specific Tendon: Identify which tendon(s):

  • Supraspinatus

  • Infraspinatus

  • Subscapularis

  • Teres minor

Common Synonyms

• "Torn shoulder"

• "Shoulder tendon tear"

• "Rotator injury"

• "Shoulder strain"

• "Pitcher's shoulder"

Coding Conflicts

Excludes1:

• Traumatic rupture of rotator cuff (S46.0-)

• Shoulder strain without tear (M25.51-)

Excludes2:

• Calcific tendinitis of shoulder (M75.3)

• Shoulder impingement syndrome (M75.4)

Scribing.io Automation

The AI scribe automatically identifies and captures:

• Anatomical terms indicating specific tendons

• Descriptors of tear size/completeness

• Temporal language indicating acuity

• Mechanism of injury when mentioned

• Laterality markers

• Associated pathologies in the same anatomical region

Keywords are mapped to appropriate ICD-10 codes while maintaining context for accurate documentation.