Subluxation of unspecified scapula, initial encounter

This code signifies a partial dislocation of the shoulder blade (scapula) where the joint surfaces are no longer perfectly aligned but remain in contact. It indicates that this is the first time the patient is being treated for this specific injury.

Apply this code when a patient presents with symptoms of a subluxed scapula, such as pain, limited range of motion, or visible deformity, and it is the initial episode of care for this injury. This is appropriate for cases where the specific side (left or right) of the injury is not documented.

• Ensure documentation clearly states "subluxation" and not a full "dislocation."
• Only use the "A" seventh character for the initial encounter for treatment of the injury.
• Avoid using this code if the laterality (left or right scapula) is specified in the medical record.