Superior glenoid labrum lesion of unsp shoulder, init encntr

This code signifies damage to the superior portion of the glenoid labrum, which is the rim of cartilage surrounding the shoulder socket. This type of lesion can involve tears or detachment of the labrum from the bone, often associated with the biceps tendon attachment. It indicates the initial phase of treatment for such an injury.

Apply this code when documentation confirms a superior glenoid labrum lesion without specifying the laterality (left or right shoulder). This is appropriate for the initial visit or encounter where the injury is first diagnosed and treatment is initiated. It should be used when the physician's notes do not provide enough detail to specify which shoulder is affected.

• Only use this code when the medical record explicitly states "unspecified shoulder."
• Ensure the "A" for initial encounter is appropriate for the patient's current stage of care.
• Always query the provider for laterality if not documented to allow for a more specific code.