Other rupture of muscle (nontraumatic), right shoulder

This code signifies a spontaneous, non-traumatic tear or disruption of muscle tissue within the right shoulder region. This condition typically results from degenerative changes, overuse, or underlying systemic diseases rather than an acute external injury.

Apply this code when documentation clearly indicates a non-traumatic rupture of a muscle in the right shoulder, such as a spontaneous tear of the deltoid or rotator cuff muscle (excluding traumatic tears). Supporting documentation should specify the non-traumatic etiology and the affected side.

• Differentiate carefully between traumatic (S46.-) and non-traumatic (M62.1-) muscle ruptures based on physician documentation.
• Ensure the laterality (right shoulder) is explicitly stated in the medical record to support this specific code.
• Do not use this code for tendon ruptures; refer to the M66.- series for spontaneous tendon ruptures.