Sprain of unspecified rotator cuff capsule, sequela

This code signifies a sprain of the fibrous capsule surrounding the rotator cuff, where the specific muscles involved are not documented. It indicates that the injury is a long-term consequence or late effect of an initial sprain, rather than an acute event.

Use this code when documentation indicates a patient is presenting for treatment of a chronic or residual issue directly resulting from a past, unspecified rotator cuff capsule sprain. This would apply to conditions like persistent pain, stiffness, or limited range of motion that are sequelae of the original injury.

• Always ensure the documentation explicitly states "sequela" or indicates a chronic condition resulting from a past sprain.
• If the specific rotator cuff muscle involved (e.g., supraspinatus, infraspinatus) is documented, a more specific code should be used.
• This code requires a seventh character "S" for sequela, indicating a late effect.