Strain of musc/fasc/tend at shldr/up arm, right arm, subs

This code signifies a non-traumatic injury to muscles, fascia, or tendons in the right shoulder or upper arm, excluding the rotator cuff, biceps, or triceps. It indicates an overstretching or tearing of these soft tissues.

This code is appropriate for follow-up visits or subsequent care for a patient previously diagnosed with a strain of the specified muscles, fascia, or tendons. This includes situations like physical therapy sessions, re-evaluations, or monitoring healing progress after the initial injury.

• Ensure the documentation clearly specifies the right arm and that the injury is a strain, not a sprain or tear.
• Verify that this is a subsequent encounter for the injury, not the initial treatment.
• Confirm that the affected muscles/tendons are not the rotator cuff, biceps, or triceps, as those have more specific codes.