Unsp superficial injury of unspecified shoulder, init encntr

This code signifies a superficial injury to the shoulder where the specific nature of the injury (e.g., abrasion, contusion, blister) is not documented, nor is the specific shoulder (left or right) identified. It indicates the initial treatment for such an injury, implying the patient is presenting for the first time for this particular issue.

Use this code when documentation clearly states a superficial shoulder injury but lacks detail regarding the specific type of injury or laterality. This is appropriate for initial encounters where further diagnostic workup or more specific details are pending. Avoid using this code if more precise information is available in the medical record.

• Only use this code when the documentation explicitly states "unspecified" for both the type of superficial injury and the shoulder laterality.
• Always strive for a more specific code if the documentation allows, such as S40.011A (Contusion of right shoulder, initial encounter).
• The "A" seventh character indicates an initial encounter for this injury. Subsequent encounters would use "D" for subsequent or "S" for sequela.