Strain of musc/tend the rotator cuff of unsp shoulder, init

This code signifies a non-traumatic injury to the muscles and/or tendons that stabilize the shoulder joint, specifically the rotator cuff, without specifying which shoulder is affected. It indicates an overstretching or tearing of these tissues, resulting in pain and functional limitation.

Apply this code for initial evaluations of patients presenting with symptoms consistent with a rotator cuff strain, such as shoulder pain, weakness, or limited range of motion, when the specific shoulder involved is not documented. This is appropriate when the injury is due to overuse or a minor, non-forceful event.

• Only use this code when the documentation explicitly states "unspecified shoulder."
• Ensure the encounter is the initial treatment for this specific injury.
• If the specific shoulder (left or right) is documented, use a more specific code.