Complete ICD-10-CM coding and documentation guide for icd-10 coding for shoulder injury includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Shoulder Injury
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 associated pain symptoms.
Stiffness of left shoulder
Use to document associated stiffness.
The ICD-10 code for a shoulder injury varies based on the specific condition, such as S46.011A for an acute rotator cuff tear or S42.255A for a displaced fracture.
For an acute rotator cuff tear, use S46.011A if it is the initial encounter. Ensure MRI confirmation and document the mechanism of injury.