Inj unsp musc/fasc/tend at shldr/up arm, unsp arm, init

Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm, initial encounter

📋Clinical Description

This code signifies an injury to a muscle, fascia, or tendon in the shoulder or upper arm region where the specific muscle, fascia, or tendon involved is not documented. It also indicates that the affected arm (left or right) is not specified in the medical record. This code is for the initial treatment of such an injury.

🎯When to Use

This code is appropriate when documentation clearly indicates an injury to a muscle, fascia, or tendon in the shoulder or upper arm, but lacks specificity regarding the exact anatomical structure or laterality. It should be used for the first encounter for treatment of this particular injury.

💡Coding Tips

Only use this code when the documentation truly lacks specificity regarding the injured muscle/fascia/tendon and laterality.
Always query the provider for more specific information regarding the injured structure and laterality before resorting to this unspecified code.
Ensure the "A" for initial encounter is appropriate; subsequent encounters will require different seventh characters.

AI-generated reference — verify against official guidelines

Code Hierarchy

▲S46.999Inj unsp muscle, fascia and tendon at shldr/up arm, unsp arm

S46.999A(current)

Crosswalks

959.2ApproxICD-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