M75.21 Bicipital tendinitis, right shoulder

ICD10CM code

#### Name of the Condition
- Bicipital tendinitis, right shoulder
- Also known as biceps tendonitis or proximal biceps tendinitis

#### Summary
Bicipital tendinitis refers to inflammation of the long head of the biceps tendon. It occurs where the tendon attaches to the shoulder. This condition can cause shoulder pain and limit the mobility of the arm. Typically, it affects the dominant arm—commonly the right shoulder.

#### Causes
- Repetitive overhead activities or tasks involving the shoulder
- Acute injury or trauma to the shoulder
- Degenerative changes due to aging

#### Risk Factors
- Engaging in sports that involve repetitive shoulder motions, such as tennis, baseball, or swimming
- Advanced age, leading to wear and tear of tendons
- Poor shoulder mechanics or posture

#### Symptoms
- Pain or tenderness in the front of the shoulder
- Pain that worsens with overhead movements or lifting
- Weakness or fatigue in the shoulder
- Clicking or snapping sound during shoulder movement

#### Diagnosis
- Physical examination evaluating for pain or tenderness in the shoulder
- Medical imaging such as MRI or ultrasound to view inflammation or tears
- Orthopedic evaluation to assess movement and pain

#### Treatment Options
- Rest and avoiding activities that aggravate the tendon
- Nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief
- Physical therapy to strengthen and stretch the shoulder muscles
- Corticosteroid injections to reduce inflammation
- Surgery in severe cases where conservative treatments fail

#### Prognosis and Follow-Up
Most people experience improvement with conservative treatment and physical therapy. Regular follow-up with healthcare providers ensures recovery is on track and adjustments to the treatment plan are made if necessary.

#### Complications
If untreated or poorly managed, bicipital tendinitis may lead to chronic shoulder pain, decreased range of motion, or a rotator cuff tear.

#### Lifestyle & Prevention
- Gradually increasing intensity of shoulder activities can prevent strain
- Incorporating strength training and flexibility exercises for shoulder muscles
- Ensuring proper techniques in sports or repetitive tasks

#### When to Seek Professional Help
- Persistent shoulder pain despite rest and home care
- Severe pain or a sudden increase in discomfort
- Weakness, numbness, or inability to move the shoulder

#### Additional Resources
- American Academy of Orthopaedic Surgeons (AAOS)
- National Institutes of Health (NIH)
- Physical Therapy and Sports Medicine Clinics

#### Tips for Medical Coders
- Ensure documentation specifies laterality; i.e., right shoulder for accurate coding
- Verify any underlying conditions or previous injuries documented as contributing factors
- Be mindful of potential coding errors, such as mistaking lateral shoulder pain for general shoulder pain (M75.20 vs. M75.21)

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