Synovial hypertrophy, NEC, right shoulder

This code signifies an abnormal overgrowth or thickening of the synovial membrane within the right shoulder joint. This hypertrophy is not attributable to a specific underlying condition like infection, autoimmune disease, or trauma, and often leads to pain, swelling, and restricted joint movement.

Apply this code when documentation explicitly states synovial hypertrophy of the right shoulder, and no other more specific diagnosis (e.g., rheumatoid arthritis, gout, infection) is identified as the cause. Supporting documentation would include imaging reports (MRI, ultrasound) detailing synovial thickening and physician notes confirming the diagnosis and ruling out other etiologies.

• Ensure laterality (right shoulder) is clearly documented.
• Do not use this code if a more specific cause for the synovial hypertrophy is identified; instead, code the underlying condition.
• Consider sequencing this code after a pain code (e.g., M25.511) if pain is the primary reason for the encounter.