Inflammatory condition of the bursal sac(s) of the left shoulder, encompassing subacromial, subdeltoid, subcoracoid, and scapulothoracic bursae on the left side.

Documentation tips

What should appear in the chart to support M75.52.

Source · Editorial brief grounded in 6 cited references ↓

• Explicitly state 'left shoulder' in the assessment — the laterality word must appear in the provider's note, not inferred from a diagram or image header alone.
• Specify the bursa involved when known (subacromial, subdeltoid, subcoracoid, scapulothoracic) to support medical necessity and differentiate from unspecified shoulder lesion codes.
• Record imaging findings that confirm bursitis: ultrasound showing subacromial effusion or synovial thickening, or MRI demonstrating bursal fluid signal — include the modality and the positive finding in the note.
• Document functional impact (limited abduction, painful arc, ROM restriction) and any conservative care already attempted (PT, NSAIDs, prior injections) to support medical necessity for procedures.
• If the presentation is bilateral, document both sides explicitly so each can be coded separately (M75.52 + M75.51); do not use M75.52 as a bilateral code — it is left-only.
• If infectious etiology is suspected (fever, elevated WBC, recent procedure), document the workup results; infectious bursitis is excluded from M75.52 and requires a different code pathway.

Related CPT procedures

Procedure codes commonly billed with M75.52. Linking the right diagnosis to the right procedure is what establishes medical necessity.

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

Common coding pitfalls

The recurring mistakes coders make with M75.52 and adjacent codes.

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

• Assigning M75.52 when the note documents only 'shoulder bursitis' without specifying left — use M75.50 (unspecified) until laterality is confirmed in the record.
• Using M75.52 for infectious (septic) bursitis of the left shoulder — the M75.5x subcategory excludes infectious bursitis; route those encounters through the appropriate infectious organism codes (B95–B97) plus a soft tissue infection code.
• Coding M75.52 alone when concurrent left shoulder impingement syndrome (M75.42) is separately documented — both diagnoses may be reportable if clinically distinct and documented as such.
• Confusing subacromial impingement with bursitis and defaulting to M75.52 — if the provider's primary diagnosis is impingement syndrome, M75.42 is the correct first-listed code, even when bursitis is a component.
• Reporting M75.52 as both left and bilateral — the code is strictly left-sided; there is no single M75.5x code for bilateral bursitis; code M75.51 and M75.52 together for bilateral presentations.

Clinical context

Source · Editorial summary grounded in 6 cited references ↓

Sibling codes

Other billable codes under M75.5 (laterality / anatomic variants).