Separation of muscle (nontraumatic), right shoulder

This code signifies a spontaneous, non-traumatic detachment or tearing of muscle fibers in the right shoulder. This condition is not caused by an external injury but rather by underlying factors such as overuse, degenerative changes, or inflammatory processes. It results in pain, weakness, and impaired range of motion in the affected shoulder.

Use this code when documentation clearly indicates a non-traumatic separation of muscle tissue specifically in the right shoulder. This typically involves a diagnosis made through physical examination, imaging studies (e.g., MRI, ultrasound) confirming muscle discontinuity without evidence of acute injury. Ensure the physician explicitly states the non-traumatic etiology.

• Differentiate from traumatic muscle tears (S46.XXX codes) which involve an external force or injury.
• Confirm laterality (right shoulder) is explicitly documented; do not assume.
• Ensure the documentation specifies "separation" or "detachment" of muscle, not just strain or sprain.