Sprain of right rotator cuff capsule, subsequent encounter

This code signifies a sprain of the fibrous capsule surrounding the rotator cuff tendons in the right shoulder. It indicates that the patient is receiving follow-up care for an injury that has already been diagnosed and for which initial treatment has been provided.

Apply this code when a patient presents for ongoing management, such as physical therapy, follow-up appointments, or medication adjustments, for a previously diagnosed right rotator cuff capsule sprain. This includes situations where the patient is recovering from the initial acute phase of the injury.

• Ensure documentation clearly specifies a "sprain" of the rotator cuff capsule, not a tear.
• Confirm the encounter is for subsequent care, not the initial treatment of the injury.
• Verify the laterality is explicitly documented as "right" to support this specific code.