Fistula, right shoulder

This code signifies the presence of an abnormal, open tract or passage originating from or involving the right shoulder joint. This tract typically connects the joint space to another body surface (e.g., skin) or another organ, allowing for discharge of fluid or pus. It indicates a pathological communication that should not naturally exist.

Use this code when documentation clearly states a fistula of the right shoulder, often observed in cases of chronic infection (e.g., osteomyelitis, septic arthritis), post-surgical complications, or inflammatory conditions. Supporting documentation should include physician notes detailing the presence, location, and laterality of the fistula.

• Always confirm laterality (right vs. left) from the documentation; do not assume.
• Distinguish from sinus tracts, which are blind-ended and do not connect two epithelialized surfaces.
• Code any underlying cause of the fistula (e.g., infection, trauma) as an additional diagnosis.