Sprain of unspecified rotator cuff capsule, init encntr

This code signifies a sprain of the connective tissue surrounding the rotator cuff muscles, where the specific capsule involved (e.g., anterior, posterior) is not documented. It indicates the patient is receiving initial treatment for this injury.

Apply this code when documentation confirms a rotator cuff capsule sprain, but the physician does not specify which part of the capsule is affected. This is appropriate for the first encounter for this particular injury, such as in an emergency department or initial office visit.

• Ensure the documentation clearly states "sprain" and "rotator cuff capsule."
• Only use this code when the specific capsule is truly unspecified; avoid using it if more precise information is available.
• The "A" seventh character indicates an initial encounter for active treatment of the injury.