Encounter — Catherine Brooks
Procedure | Dr. Sarah Chen | 2/17/2026
Pipeline Status
Received
CDI Review
AI Coding
Compliance
Denial Check
Ready
Submitted
Clinical Note
Right shoulder subacromial injection. Patient with chronic right shoulder impingement syndrome, failed 6 weeks of physical therapy and oral NSAIDs. Point of maximal tenderness over subacromial bursa. Under sterile technique, 25-gauge needle inserted into subacromial space. Aspirated — no fluid. Injected 1mL betamethasone 6mg/mL + 4mL 1% lidocaine. Patient tolerated well. Post-procedure ROM improved. Return in 4 weeks.
Coding Results
ICD-10-CM Diagnoses
M75.111Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic
86%M75.41Impingement syndrome of right shoulder
94%CPT Procedures
20610Arthrocentesis, aspiration and/or injection, major joint
96%99213Office visit, established patient, low complexity
91%Details
- Patient
- Catherine Brooks
- Provider
- Dr. Sarah Chen
- Specialty
- Orthopedic Surgery
- Payer
- UnitedHealthcare
- Visit Type
- Procedure
- Date of Service
- 2/17/2026
- Revenue Impact
- $245
CDI Review
QUERY
Findings (3)
- Missing laterality documentation for impingement syndrome — confirm right vs left shoulder
- Clinical note does not document prior imaging results (MRI/X-ray) — payers may require for medical necessity
- Consider adding specificity: partial vs full-thickness rotator cuff tear
Compliance Check
83/ 100
Denial RiskMedium Risk
Payer: UnitedHealthcare