Sprain of right rotator cuff capsule, sequela

This code signifies a chronic or residual condition resulting from a past sprain of the connective tissue surrounding the rotator cuff in the right shoulder. It indicates that the patient is experiencing ongoing effects, such as pain, stiffness, or limited range of motion, directly attributable to the previous injury. This is not an acute injury but rather a long-term complication.

Apply this code when documenting a patient presenting with persistent symptoms related to a previously diagnosed right rotator cuff capsule sprain, after the initial healing phase has passed. This would include follow-up visits for chronic pain management, rehabilitation for residual functional deficits, or evaluation of long-term instability stemming from the original sprain.

• Always use this code as a secondary diagnosis, following the code for the specific sequela (e.g., chronic pain, stiffness).
• Ensure documentation clearly links the current symptoms to the past right rotator cuff capsule sprain.
• Do not use for acute or subacute sprains; those require codes from the initial or subsequent encounter categories.