Sprain of left rotator cuff capsule, subsequent encounter

This code signifies a sprain of the fibrous capsule surrounding the rotator cuff muscles in the left shoulder, indicating damage to the ligaments that stabilize the joint. It specifically applies to a patient who is receiving follow-up care for this injury after the initial treatment phase.

Use this code for patients presenting for subsequent visits related to a left rotator cuff capsule sprain, such as physical therapy, follow-up examinations, or medication management after the initial diagnosis and treatment. This applies when the patient is in the healing or recovery phase, not the acute injury phase.

• Ensure documentation clearly specifies "left" shoulder and "rotator cuff capsule" sprain.
• Verify the encounter is for follow-up care, not the initial injury or an acute exacerbation.
• Distinguish from other rotator cuff injuries like tears (S46.-) or unspecified sprains (S43.92-).