Sprain of right rotator cuff capsule, initial encounter

This code signifies a tearing or stretching injury to the fibrous capsule surrounding the right shoulder's rotator cuff muscles. This type of sprain affects the connective tissue that helps stabilize the shoulder joint, rather than the muscle tendons themselves. Patients typically experience pain, swelling, and limited range of motion in the affected shoulder.

Apply this code when documenting an initial visit for a patient presenting with a sprain of the right rotator cuff capsule. This often occurs following acute trauma, such as a fall onto an outstretched arm or a sudden, forceful movement of the shoulder. It is appropriate for the first encounter where the injury is evaluated and treatment initiated.

• Ensure documentation clearly specifies "capsule" involvement, not just a general rotator cuff sprain.
• Verify the laterality is "right" and that this is the patient's initial encounter for this specific injury.
• Differentiate from rotator cuff tendon tears (S46.-) or other shoulder sprains (S43.9-).