Unsp inj musc/fasc/tend at shldr/up arm, unsp arm, subs

Unspecified injury of other muscles, fascia and tendons at shoulder and upper arm level, unspecified arm, subsequent encounter

📋Clinical Description

This code signifies a follow-up encounter for an unspecified injury to muscles, fascia, or tendons in the shoulder and upper arm region, where the specific nature of the injury (e.g., strain, tear) is not documented. It also indicates that the affected arm was not specified in the medical record.

🎯When to Use

This code is appropriate for subsequent visits when a patient is receiving ongoing care for an uncharacterized muscle, fascia, or tendon injury in the shoulder/upper arm, and the laterality (left or right arm) is not specified. It would be used after the initial treatment has begun, but the injury's exact type remains unknown or unrecorded.

💡Coding Tips

Ensure the documentation clearly indicates a subsequent encounter for the injury.
Only use this code when the specific muscle, fascia, or tendon injury type is not documented.
Avoid this code if the laterality (left or right arm) is specified in the medical record; a more specific code would be available.

AI-generated reference — verify against official guidelines

Code Hierarchy

▲S46.809Unsp injury of musc/fasc/tend at shldr/up arm, unsp arm

S46.809D(current)

Crosswalks

V58.89ApproxICD-9

Same Category

S46Injury of muscle, fascia and tendon at shldr/up arm S46.0Injury of musc/tend the rotator cuff of shoulder S46.00Unsp injury of musc/tend the rotator cuff of shoulder S46.001Unsp injury of musc/tend the rotator cuff of right shoulder S46.001A