Superior glenoid labrum lesion of right shoulder, init

This code signifies a tear or injury to the superior portion of the glenoid labrum, a rim of cartilage surrounding the shoulder socket, specifically in the right shoulder. This type of lesion often involves the attachment point of the biceps tendon, commonly referred to as a SLAP (Superior Labrum Anterior Posterior) tear.

Apply this code for initial encounters with patients presenting with a newly diagnosed superior glenoid labrum lesion of the right shoulder. This diagnosis is typically confirmed through imaging studies like MRI or arthroscopy following a traumatic event or repetitive overhead activity.

• Ensure documentation specifies "superior" and "right shoulder" to support this precise code.
• Confirm the encounter is indeed the "initial encounter" for this specific injury. Subsequent encounters will require a different seventh character.
• Look for associated documentation of mechanism of injury, such as falls, sports injuries, or chronic overuse.