R62.50 - Unspecified lack of expected normal physiological development in childhood

Clinical Definition

A strain or tear of muscle(s) and tendon(s) of the rotator cuff of the shoulder joint, characterized by damage to one or more of the four rotator cuff muscles (supraspinatus, infraspinatus, teres minor, and subscapularis).

Documentation Requirements

• Laterality - Must specify:

  • Right shoulder

  • Left shoulder

  • Bilateral shoulders

• Acuity - Document:

  • Acute

  • Chronic

  • Acute-on-chronic

• Anatomical Detail:

  • Specific muscle/tendon involved (if known)

  • Complete vs. partial tear

  • Size of tear (small, medium, large, massive)

• Mechanism of Injury:

  • Initial injury

  • Traumatic vs. degenerative

  • Work-related if applicable

• Imaging Confirmation:

  • MRI findings if available

  • Ultrasound results if performed

Common Synonyms

• Rotator cuff tear

• Shoulder strain

• Shoulder tendon injury

• Torn shoulder

• Cuff injury

Coding Conflicts

• Excludes1:

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

  • Rupture of shoulder biceps tendon (M66.82-)

• Excludes2:

  • Shoulder impingement syndrome (M75.4-)

  • Calcific tendinitis of shoulder (M75.3)

Scribing.io Automation

The AI scribe automatically identifies:

• Key phrases indicating tear location ("supraspinatus tear")

• Laterality mentions ("right shoulder")

• Acuity descriptors ("chronic tear")

• Measurement terms for tear size

• Associated imaging findings

• Creates structured documentation that maps directly to coding requirements while maintaining narrative flow