Unsp injury of musc/fasc/tend long hd bicep, right arm, init

This code signifies an unspecified injury to the muscle, fascia, or tendon of the long head of the biceps brachii in the right arm. It indicates that the specific nature of the injury (e.g., strain, tear, rupture) is not documented or determined at the time of the initial encounter.

This code is appropriate for initial evaluations of right arm pain or dysfunction where imaging or clinical assessment has not yet definitively identified the exact type or severity of a biceps long head injury. It is used when the provider suspects an injury to this specific anatomical structure but lacks further diagnostic detail.

• Ensure the documentation clearly specifies the "right arm" and "long head of biceps."
• Only use for the initial encounter for this specific injury. Subsequent encounters will require a different seventh character.
• Avoid this code if a more specific diagnosis (e.g., S46.111A for strain) is documented.