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

This diagnosis indicates a muscle, fascia, or tendon strain in the right shoulder or upper arm region, where the specific muscle or tendon involved is not documented. The "D" seventh character signifies that this is a subsequent encounter for care of the initial injury, such as during a follow-up visit or during the healing phase.

This code is appropriate for documenting follow-up care for a right shoulder or upper arm strain when the specific anatomical structure affected (e.g., biceps, deltoid) was not identified or recorded at the time of initial diagnosis. It is used when the patient is receiving routine care during the healing or recovery phase, after the initial treatment has been rendered.

• Ensure documentation clearly states the encounter is subsequent for this specific injury.
• Avoid using this code if a more specific muscle or tendon strain is documented; always code to the highest level of specificity.
• Do not use for initial encounters or for sequelae of the injury.