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

This code signifies a persistent or late-effect strain of muscles, fascia, or tendons in the right shoulder and upper arm region, excluding rotator cuff injuries. It indicates that the initial acute injury has resolved, but the patient continues to experience symptoms or functional limitations directly attributable to the prior strain.

Use this code when a patient presents with ongoing pain, weakness, or restricted movement in the right shoulder/upper arm due to a previously sustained muscle, fascia, or tendon strain. This is appropriate for follow-up encounters where the sequelae of an old injury are being addressed, rather than an acute event.

• Always assign a code for the underlying cause of the initial strain if known and still relevant.
• Ensure documentation clearly supports the "sequela" nature of the condition, indicating a prior injury and current residual effects.
• Differentiate from acute strains (S46.811A) and subsequent encounters for acute strains (S46.811D) by the "S" seventh character.