Pain in unspecified shoulder

This code signifies the presence of pain localized to a shoulder joint, without further specification of which shoulder (left or right) or the underlying etiology. It indicates a symptom rather than a definitive diagnosis of a specific shoulder pathology.

This code is appropriate when documentation clearly states "shoulder pain" but does not specify laterality (e.g., "patient presents with shoulder pain"). It should be used when the provider has not yet determined the specific cause of the pain or when the documentation lacks sufficient detail to assign a more specific code.

• Avoid using this code if the documentation specifies "right shoulder pain" or "left shoulder pain"; instead, use M25.511 or M25.512, respectively.
• Always strive for a more specific code if the documentation allows, as this code indicates unspecified laterality and etiology.
• This code should often be followed by additional codes that describe the underlying cause of the pain, if known, such as rotator cuff tear (S46.01-), impingement syndrome (M75.4-), or osteoarthritis (M19.01-).