Effusion, right shoulder

This code signifies the presence of excess fluid within the right shoulder joint capsule. This accumulation can lead to swelling, pain, and restricted range of motion in the affected shoulder. It is a non-specific finding, indicating an underlying inflammatory or traumatic process.

Apply this code when documentation explicitly states "effusion of the right shoulder" or "fluid in the right glenohumeral joint." This diagnosis is often supported by imaging studies such as ultrasound, MRI, or X-ray, or by physical examination findings. It is typically used as a secondary diagnosis, pointing to a symptom rather than a definitive etiology.

• Always code the underlying cause of the effusion (e.g., arthritis, injury) as the primary diagnosis, if known.
• Do not use this code for generalized edema or swelling around the shoulder that is not specifically intra-articular.
• Ensure laterality is clearly documented; differentiate between right, left, or bilateral shoulder involvement.