M75.22

Inflammation of the bicipital tendon at the left shoulder, specifically involving the long head of the biceps brachii as it travels through the bicipital groove.

Verified May 8, 2026 · 7 sources ↓

Status: Billable
Chapter: 13
Related CPT: 7
Region: Shoulder

Drawn from CDCICD10DataCMSOrthoInfoIcdcodes

Documentation tips

What should appear in the chart to support M75.22.

Source · Editorial brief grounded in 7 cited references ↓

Explicitly state 'left shoulder' in the diagnosis line — 'bicipital tendinitis' alone without laterality forces a drop to M75.20 (unspecified).
Record the results of Speed's test and Yergason's test; positive findings clinically validate biceps tendon involvement and support audit defense.
Document imaging findings that support the diagnosis: MRI signal change in the bicipital groove, ultrasound tendon sheath fluid ≥3mm, or peritendinous edema.
Note prior conservative treatment (NSAIDs, physical therapy, rest, ice) in the history when proceeding to injection, as CMS requires clinical indication of necessity for CPT 20550.
If injecting under ultrasound guidance, document image guidance separately to support billing CPT 76942 alongside 20550.

Related CPT procedures

Procedure codes commonly billed with M75.22. Linking the right diagnosis to the right procedure is what establishes medical necessity.

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

20550 $60.46

Injection into a single tendon sheath, ligament, or aponeurosis (such as the plantar fascia) — one anatomical site per unit.

20551 $60.46

Injection of a therapeutic substance into the origin or insertion point of a single tendon, used to treat tendinitis, enthesopathy, or localized inflammation at the bone-tendon junction.

23000 $571.49

Open surgical removal of calcium deposits located beneath the deltoid muscle in the shoulder (subdeltoid region).

23020 $650.65

Open surgical release of a contracted shoulder joint capsule to restore glenohumeral range of motion, typically performed for adhesive capsulitis or post-traumatic stiffness.

29827 $976.31

Arthroscopic surgical repair of the rotator cuff, performed entirely through the shoulder joint via endoscopic technique.

73221 $205.08

MRI of any upper extremity joint — shoulder, elbow, or wrist — performed without contrast material.

76942 View procedure details

Common coding pitfalls

The recurring mistakes coders make with M75.22 and adjacent codes.

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

Defaulting to M75.20 (unspecified shoulder) when the note clearly states left — always capture laterality if documented.
Using M75.22 alongside M75.122 (complete rotator cuff tear, left) when the rotator cuff tear is the primary diagnosis — the Excludes note under M75.2 directs coders away from bicipital tendinitis codes when a rotator cuff tear is the documented pathology.
Reporting CPT 20551 (tendon origin/insertion injection) instead of 20550 (tendon sheath injection) for a bicipital tendon sheath injection — these are anatomically distinct and not interchangeable.
Billing M75.22 for a bilateral presentation without also coding M75.21 — bilateral bicipital tendinitis requires both M75.21 and M75.22; there is no single bilateral code in this subcategory.

Clinical context

Source · Editorial summary grounded in 7 cited references ↓

M75.22 is the correct code when a clinician has documented bicipital tendinitis with explicit left-side laterality. It covers inflammation of the long head of the biceps tendon within the bicipital groove — diagnosed through a combination of anterior shoulder pain, tenderness over the groove, and positive provocative tests (Speed's, Yergason's), with imaging support such as MRI or ultrasound showing tendon sheath fluid or peritendinous inflammation. Drop to M75.20 only when the operative or clinical report fails to specify left versus right.

M75.22 sits within the M75 shoulder lesion block and carries no 7th-character requirement. It maps to MS-DRG 557 (Tendonitis, myositis and bursitis with MCC) or 558 (without MCC) under MS-DRG v43.0. CMS explicitly lists M75.22 as a covered ICD-10-CM code supporting medical necessity for tendon sheath injections (CPT 20550) and related pain management procedures per CMS LCD A52863.

Do not use M75.22 when the primary pathology is a rotator cuff tear — those map to M75.1x codes. If the encounter documents concurrent impingement syndrome of the left shoulder, add M75.42 as a secondary code, since both conditions can coexist and each is separately reportable.

Sibling codes

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

M75.21

Bicipital tendinitis, right shoulder

M75.20

Bicipital tendinitis, unspecified shoulder

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 7 cited references ↓

01What is the difference between M75.22 and M75.20?

M75.22 specifies the left shoulder; M75.20 is unspecified laterality. Use M75.22 whenever the documentation names the left side. M75.20 is a fallback only when laterality is genuinely absent from the record.

02Can M75.22 and M75.42 (impingement syndrome, left shoulder) be billed together?

Yes. Bicipital tendinitis and impingement syndrome of the same shoulder are separately classifiable conditions with no Excludes relationship between them. Report both codes if both are documented and clinically supported.

03Does M75.22 support CPT 20550 for a bicipital tendon sheath injection?

Yes. CMS explicitly lists M75.22 as an ICD-10-CM code supporting medical necessity for tendon sheath injections in both CMS LCD A52863 and the related Draft Article DA52863. Ensure the procedure note documents the specific tendon sheath injected and the medication used.

04How do I code bilateral bicipital tendinitis?

There is no single bilateral code under M75.2. Report M75.21 (right) and M75.22 (left) together. Some reference synonyms list 'biceps tendinitis of bilateral shoulders' under M75.22, but that does not make M75.22 a bilateral code — use both laterality-specific codes.

05Is M75.22 valid when bicipital tendinitis co-exists with a left rotator cuff tear?

Exercise caution. The Tabular List includes an Excludes note under M75.2 directing away from bicipital tendinitis when a rotator cuff tear is the documented pathology. If the rotator cuff tear (M75.12x) is the primary condition, code that first and confirm whether bicipital tendinitis is a separately documented, independently treated condition before stacking M75.22.

06Does M75.22 require a 7th character?

No. M75.22 is a fully specified 5-character code with no 7th-character extension required. The 7th-character rules apply to injury S-codes, not to M-category musculoskeletal codes.

07What imaging finding best supports M75.22 for audit purposes?

MRI demonstrating increased T2 signal in or around the bicipital groove, or ultrasound showing tendon sheath fluid ≥3mm, are the strongest objective findings. Document the modality, finding, and the affected side explicitly in the assessment.

Sources & references

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

Mira AI Scribe

Mira's AI scribe captures left-side laterality, anterior shoulder pain location, bicipital groove tenderness, Speed's and Yergason's test results, and any imaging findings (MRI signal change, ultrasound tendon sheath fluid) from the encounter note. This prevents a lateral downcode to M75.20 and ensures the documentation package satisfies CMS medical necessity requirements for tendon sheath injection claims under CPT 20550.

See how Mira captures M75.22 documentation