Complete ICD-10-CM coding and documentation guide for icd-10 coding for right shoulder 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 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
Pain in right shoulder
Use to document pain when it is the primary symptom without a specific traumatic injury.
Other specified injuries of right shoulder and upper arm, initial encounter
Use for other specified injuries not classified elsewhere.
The ICD-10 code for right shoulder trauma, specifically a rotator cuff strain, is S46.011A for the initial encounter.
Document the mechanism of injury, laterality, physical exam findings, and imaging results to ensure accurate coding.