Rotator cuff (capsule) sprain

This code signifies a non-traumatic injury to the rotator cuff, specifically a sprain or strain of the ligaments and capsule surrounding the shoulder joint. It indicates damage to the fibrous tissues connecting the bones of the shoulder, without a complete tear or dislocation. This injury typically results in pain, limited range of motion, and weakness in the affected shoulder.

Apply this code when documentation clearly indicates a sprain or strain of the rotator cuff or its capsule, often due to overuse, repetitive motion, or a minor twist. Supporting documentation should specify "sprain," "strain," or "capsulitis" of the rotator cuff, without evidence of a full tear (e.g., from imaging reports or operative notes).

• Differentiate carefully from rotator cuff tears (e.g., 840.6 for unspecified tear), which represent a more severe injury.
• Ensure documentation specifies "sprain" or "strain" rather than just "shoulder pain" to justify this code.
• Consider an additional E-code if the cause of the sprain (e.g., fall, sports injury) is known and documented.