Complete ICD-10-CM coding and documentation guide for icd-10 coding for right shoulder supraspinatus tear due to trauma includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Right Shoulder Supraspinatus Tear Due to Trauma
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.
Additional codes that may be used with this diagnosis
Anterior dislocation of right shoulder, initial encounter
Use if there is an associated shoulder dislocation.
Injury of axillary nerve, right arm, initial encounter
Use if there is an associated nerve injury.
The ICD-10 code for a traumatic right shoulder supraspinatus tear is S46.011A, used when the injury is due to trauma and confirmed by imaging.
Document the mechanism of injury, immediate symptoms, and imaging results confirming the tear to ensure accurate coding.