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

This code indicates a long-term complication or late effect resulting from an injury to an unspecified muscle, fascia, or tendon in the shoulder or upper arm region. The specific nature of the original injury is not documented, nor is the affected arm specified. This diagnosis signifies that the acute phase of the injury has passed, and the patient is now experiencing residual symptoms or conditions directly attributable to that past trauma.

This code is appropriate when documentation clearly states a sequela (e.g., chronic pain, limited range of motion, weakness, scar tissue) from a previous, unspecified muscle, fascia, or tendon injury of the shoulder or upper arm. It should be used when the laterality (left or right arm) is not specified in the medical record. This code is also applicable when the exact muscle, fascia, or tendon involved is not identified.

• Always sequence this sequela code after the code(s) for the specific residual condition(s) being treated.
• Avoid using this code if the original injury is still in the acute or subacute phase; instead, use an acute injury code.
• Query the provider for more specific details regarding the muscle/fascia/tendon involved and laterality if available, to allow for more precise coding.