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Home/Diagnosis/ICD-10 Coding for Shoulder Strain

ICD-10 Coding for Shoulder Strain

S46.011A
S46.012A

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

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

Essential facts and insights about ICD-10 Coding for 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:
  • • Acute onset with a clear traumatic event
documentation:
  • • Detailed physical exam and imaging findings

Applicable To

  • • Acute traumatic right rotator cuff strain

Important Notes

  • • Ensure documentation includes the mechanism of injury and laterality.

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

Billable Code
S46.012A
Billable

Diagnostic Criteria

clinical:
  • • Acute onset with a clear traumatic event
documentation:
  • • Detailed physical exam and imaging findings

Applicable To

  • • Acute traumatic left rotator cuff strain

Important Notes

  • • Ensure documentation includes the mechanism of injury and laterality.
Ancillary Codes

Additional codes that may be used with this diagnosis

W19.XXXA

Unspecified fall, initial encounter

Use to specify the external cause of the traumatic shoulder strain.

Frequently Asked Questions

What is the ICD-10 code for shoulder strain?

The ICD-10 code for a traumatic shoulder strain is S46.011A for the right shoulder and S46.012A for the left shoulder, used during the initial encounter.

How do you code a non-traumatic shoulder condition?

For non-traumatic shoulder conditions, such as a complete rotator cuff tear without trauma, use codes from the M75.1- range.

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