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

Strain of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm, subsequent encounter

📋Clinical Description

This code signifies a muscle, fascia, or tendon strain in the shoulder or upper arm region, where the specific muscle or tendon involved is not documented. It indicates that the patient is receiving follow-up care for this injury after the initial treatment.

🎯When to Use

Apply this code for subsequent encounters when a patient presents for ongoing management, healing, or rehabilitation of a shoulder/upper arm strain, and the medical record does not specify the exact muscle, fascia, or tendon affected. This is appropriate when laterality (left or right arm) is also not documented.

💡Coding Tips

Ensure the documentation clearly indicates a "subsequent encounter" for the injury.
Only use this code when the specific muscle/tendon and laterality are truly unspecified in the medical record.
Prioritize more specific codes if the documentation allows for identification of the affected structure or laterality.

AI-generated reference — verify against official guidelines

Code Hierarchy

▲S46.919Strain of unsp musc/fasc/tend at shldr/up arm, unsp arm

S46.919D(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