M75.20

Bicipital tendinitis of the shoulder when the affected side (right or left) is not documented or cannot be determined from the clinical record.

Verified May 8, 2026 · 6 sources ↓

Status: Billable
Chapter: 13
Related CPT: 12
Region: Shoulder

Drawn from CDCICD10DataAAPCIcdcodesSprypt

Documentation tips

What should appear in the chart to support M75.20.

Source · Editorial brief grounded in 6 cited references ↓

Specify laterality (right or left) in every shoulder encounter note — this single step lets you use M75.21 or M75.22 instead of the payer-flagged unspecified M75.20.
Record the result of provocative physical exam tests (Speed's test, Yergason's test) and bicipital groove palpation tenderness to establish clinical basis for the bicipital tendinitis diagnosis.
When ordering or reviewing imaging, summarize relevant findings — tendon thickening, peritendinous fluid, signal change on MRI — in the assessment to support the diagnosis over a symptom-only code.
Document prior conservative management (NSAIDs, physical therapy, corticosteroid injection) in the history to support medical necessity for ongoing or escalated treatment.
If both bicipital tendinitis and shoulder-hand syndrome are present, document both conditions explicitly — the M75 Excludes 2 note permits dual coding when both are confirmed.

Related CPT procedures

Procedure codes commonly billed with M75.20. Linking the right diagnosis to the right procedure is what establishes medical necessity.

Source · CMS LCDs · AAOS specialty guidance · claims-pattern analysis

99203 $117.57

New patient office or outpatient visit requiring a medically appropriate history and/or examination with low-complexity medical decision-making, or 30–44 minutes of total provider time on the date of the encounter.

99204 $177.36

New patient office or outpatient visit requiring moderate medical decision making, or 45–59 minutes of total provider time on the date of the encounter.

99205 $236.81

New patient office or outpatient visit requiring high-complexity medical decision making, or 60–74 minutes of total time on the date of encounter.

99213 $95.19

Established patient office or outpatient visit requiring 20–29 minutes of total time or low-complexity medical decision-making.

99214 $135.61

Office visit for an established patient requiring moderate-complexity medical decision making (MDM), or 30–39 minutes of total provider time on the date of service.

99215 $192.39

Highest-level office or outpatient E/M visit for an established patient, qualifying via high-complexity medical decision making or 40–54 minutes of total provider time on the date of service.

20610 $68.81

Aspiration and/or injection of a major joint or bursa (shoulder, hip, knee, or subacromial bursa) performed without ultrasound guidance.

73030 $35.74

Radiologic examination of the shoulder requiring a minimum of two views, reported as a single unit regardless of how many views are obtained.

97110 $29.06

Therapeutic exercise billed per 15-minute unit, targeting strength, endurance, range of motion, or flexibility with direct one-on-one patient contact.

97140 $27.72

Skilled, hands-on manual therapy techniques — including joint mobilization/manipulation, manual lymphatic drainage, and manual traction — applied to one or more body regions, billed per 15-minute unit.

99202 View procedure details

99212 View procedure details

Common coding pitfalls

The recurring mistakes coders make with M75.20 and adjacent codes.

Source · Editorial brief grounded in CDC ICD-10-CM tabular guidance, AAOS coding references, and cited references ↓

Using M75.20 when the note clearly states 'right' or 'left' shoulder — laterality that exists in the documentation must be coded; defaulting to unspecified is a specificity error and an audit risk.
Confusing bicipital tendinitis (M75.2-) with calcific tendinitis of the shoulder (M75.3-) or impingement syndrome (M75.4-) — each maps to a distinct subcategory and requires separate documentation support.
Applying a traumatic injury S-code (e.g., S40-S49 range) when the biceps tendon inflammation is degenerative or overuse-related rather than acute traumatic — M75.20 is the correct category for non-traumatic, chronic tendinitis.
Failing to update M75.20 to a laterality-specific code at follow-up once the provider has documented the affected side, leaving an indefinitely open unspecified code in the problem list.

Clinical context

Source · Editorial summary grounded in 6 cited references ↓

M75.20 is the fallback code for bicipital tendinitis when laterality is absent from the provider's documentation. The M75.2- subcategory covers inflammation of the long head of the biceps tendon within the bicipital groove, a non-traumatic, soft-tissue shoulder lesion classified under Chapter 13 (M00–M99). Use M75.21 for the right shoulder and M75.22 for the left — M75.20 is only appropriate when the note genuinely omits side.

Clinically, bicipital tendinitis presents with anterior shoulder pain, tenderness in the bicipital groove, and positive provocative tests (Speed's, Yergason's). Ultrasound or MRI may show tendon thickening, peritendinous fluid, or signal changes. When imaging findings are documented, code to the specific lateral variant. M75.20 is defensible at a first-contact urgent care visit where laterality was not recorded, but should be updated to M75.21 or M75.22 at follow-up once the chart reflects the affected side.

Note the Excludes 2 instruction at the M75 category level: shoulder-hand syndrome (M89.0-) is coded separately and can be reported alongside M75.20 when both conditions are documented. M75.20 does not use 7th-character extensions — it is a complete, billable code as listed.

Sibling codes

Other billable codes under M75.2 (laterality / anatomic variants).

M75.21

Bicipital tendinitis, right shoulder

M75.22

Bicipital tendinitis, left shoulder

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 6 cited references ↓

01When is M75.20 actually appropriate to use?

Only when the clinical documentation genuinely does not specify right or left shoulder. The clearest legitimate use case is an urgent care or emergency visit note where laterality was never recorded. At any subsequent visit where the side is documented, update to M75.21 (right) or M75.22 (left).

02What is the difference between M75.20, M75.21, and M75.22?

All three code bicipital tendinitis of the shoulder. The 6th character identifies laterality: 0 = unspecified, 1 = right, 2 = left. Use the most specific code the documentation supports — unspecified is a last resort, not a default.

03Can M75.20 be reported with a shoulder impingement code on the same claim?

Yes. Bicipital tendinitis (M75.2-) and impingement syndrome (M75.4-) are distinct conditions in the M75 category. If the provider documents both diagnoses, both codes may be reported. Ensure the note supports each diagnosis independently.

04Does M75.20 require a 7th-character extension?

No. M-codes in Chapter 13 do not use 7th-character extensions. The A/D/S encounter extensions apply only to injury codes (S- and T-codes). M75.20 is complete as a 5-character code.

05Should I use M75.20 or a symptom code like M75.80 if the diagnosis isn't confirmed?

Use the confirmed diagnosis code when the provider states a definitive diagnosis of bicipital tendinitis. If the visit note only documents shoulder pain without a named diagnosis, code the symptom. Do not assign M75.20 speculatively when the provider has not established the diagnosis.

06Can shoulder-hand syndrome be coded alongside M75.20?

Yes. The Excludes 2 note at the M75 category level means shoulder-hand syndrome (M89.0-) is not included in M75.20 but may be coded together when both conditions are documented by the provider.

07What CPT procedures are commonly reported with M75.20?

Office evaluation and management codes (99202–99215) are the most frequent. Diagnostic shoulder X-ray (73030), joint aspiration or injection (20610), and physical therapy codes (97110, 97140) are also commonly paired with this diagnosis code.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

Mira AI Scribe

The Mira AI Scribe captures the affected shoulder side, bicipital groove tenderness, results of Speed's and Yergason's tests, imaging findings (tendon thickening, fluid, MRI signal), and prior treatment history from the encounter note. That documentation drives the upgrade from M75.20 (unspecified) to M75.21 or M75.22, preventing payer-level specificity downcodes and reducing audit exposure on shoulder soft-tissue claims.

See how Mira captures M75.20 documentation