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Home/Diagnosis/ICD-10 Coding for Right Shoulder Strain

ICD-10 Coding for Right Shoulder Strain

S46.011A
M75.111

Complete ICD-10-CM coding and documentation guide for icd-10 coding for right shoulder strain includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
R Shoulder Strain
Right Rotator Cuff Strain
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Key Information: ICD-10 Coding for Right Shoulder Strain

Essential facts and insights about ICD-10 Coding for Right Shoulder Strain

Use ICD-10 code S46.011A for strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter

Billable Code
S46.011A
Billable

Diagnostic Criteria

clinical:
  • • Presence of acute trauma and localized pain
coding:
  • • Use for initial encounter of acute strain

Applicable To

  • • Acute strain of right rotator cuff

Important Notes

  • • Ensure laterality is documented. Use the correct 7th character for encounter type.

Unspecified rotator cuff tear/rupture of right shoulder, not specified as traumatic

Billable Code
M75.111
Billable

Diagnostic Criteria

clinical:
  • • Chronic symptoms over 3 months
  • • Recurrent weakness
  • • MRI-confirmed tear without acute trauma

Applicable To

  • • Chronic tear of right rotator cuff

Important Notes

  • • Ensure chronicity is documented. Differentiate from acute strains.
Ancillary Codes

Additional codes that may be used with this diagnosis

Z47.89

Encounter for orthopedic aftercare

Use for postoperative follow-up of chronic conditions.

Frequently Asked Questions

What is the ICD-10 code for right shoulder strain?

The ICD-10 code for right shoulder strain is S46.011A, used for initial encounters involving acute strain of the rotator cuff.

How do you document a right shoulder strain?

Document the mechanism of injury, laterality, specific muscle or tendon involved, and imaging results to support the diagnosis.

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