Shoulder lesion, unspecified, right shoulder

This code signifies an uncharacterized pathological change or injury affecting the right shoulder joint or surrounding soft tissues. It indicates the presence of a shoulder problem without a more specific diagnosis being established.

Use this code when documentation indicates a right shoulder lesion, but the specific nature (e.g., tear, inflammation, impingement, instability) is not yet identified or definitively diagnosed. This code is appropriate for initial encounters or when diagnostic workup is ongoing.

• Avoid using this code if a more specific diagnosis for the right shoulder is available in the medical record.
• Always seek clarification from the provider if the documentation suggests a more precise condition but lacks definitive diagnostic wording.
• Consider laterality carefully; this code is specifically for the right shoulder.