Inj musc/tend the rotator cuff of right shoulder, init

This code signifies an acute, non-specific injury to the muscles or tendons comprising the rotator cuff in the patient's right shoulder. It indicates damage beyond a simple strain or sprain, but not a complete tear, affecting the soft tissues responsible for shoulder movement and stability. The injury is recent and the patient is receiving initial treatment.

Apply this code for new presentations of right shoulder pain and dysfunction where diagnostic imaging (e.g., MRI) or clinical examination reveals an injury to the rotator cuff muscles or tendons, such as a partial tear or contusion, that is not explicitly classified elsewhere. This is appropriate when the patient is first seeking medical attention for this specific injury.

• Ensure documentation clearly specifies the right shoulder and that the encounter is for initial treatment of this injury.
• Distinguish this from a rotator cuff strain (S46.011A) or a complete tear (S46.021A or S46.041A).
• Confirm the injury involves the muscle(s) and tendon(s) of the rotator cuff, not just the bursa or other surrounding tissues.