S46.109S
ICD-10-CMUnspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm, sequela
This code signifies a long-term complication or late effect stemming from an unspecified injury to the muscle, fascia, or tendon of the long head of the biceps. The original injury's nature is not documented, and the affected arm is also not specified. This diagnosis indicates that the patient is experiencing residual issues from a past, ill-defined biceps injury.
Apply this code when a patient presents with a sequela (e.g., chronic pain, weakness, limited range of motion, scar tissue) directly attributable to an old, unspecified injury of the long head of the biceps. This is appropriate when the specific type of initial injury (e.g., strain, tear) is unknown or not documented, and the laterality of the arm is also not specified. It should be used for encounters where the sequela, not the acute injury, is being treated.
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