Lacerat unsp musc/fasc/tend at shldr/up arm, left arm, init

This code signifies a tear or cut in the muscle, fascia, or tendon structures within the left shoulder or upper arm region, where the specific affected tissue is not identified. It indicates an acute injury requiring initial treatment.

This code is appropriate for documenting the initial encounter for a patient presenting with a laceration to the left shoulder or upper arm, when the physician's documentation does not specify whether the muscle, fascia, or tendon was individually or predominantly affected. It is used when the exact tissue involved is unknown or broadly described.

• Ensure documentation clearly states "left arm" and "initial encounter."
• Only use when the specific muscle, fascia, or tendon lacerated is not identified.
• If the specific tissue (e.g., biceps muscle, rotator cuff tendon) is documented, a more specific code should be selected.