Fistula, left shoulder

This code signifies the presence of an abnormal, tunnel-like connection (fistula) originating in or around the left shoulder joint. This tract typically connects two epithelialized surfaces, such as the joint capsule to the skin, or two internal structures. It often results from infection, trauma, or surgical complications.

Use this code when documentation clearly indicates a fistula affecting the left shoulder. This includes fistulas draining pus, synovial fluid, or other contents from the joint or surrounding tissues. Documentation should specify the laterality (left shoulder) and the presence of a fistula.

• Ensure documentation specifies "fistula" and not merely a sinus tract, as these have different coding implications.
• Always confirm laterality (left shoulder) to avoid incorrect coding.
• Code any underlying cause or associated infection of the fistula separately, if documented.