Strain of musc/tend the rotator cuff of right shoulder, init

This code signifies a non-traumatic injury to the muscles and/or tendons that form the rotator cuff in the patient's right shoulder. This type of injury involves overstretching or tearing of these soft tissues, leading to pain, weakness, and limited range of motion. It does not involve a fracture or dislocation.

This code is appropriate for the initial visit or encounter where a patient presents with a newly diagnosed strain of the right rotator cuff. This includes acute injuries from activities like lifting, throwing, or falls, as well as the initial assessment of overuse injuries. It should be used when the patient is receiving active treatment for the condition.

• Always confirm laterality (right vs. left) and the specific encounter type (initial, subsequent, sequela).
• Distinguish between a strain (S46.01-) and a tear (S46.02-) of the rotator cuff.
• Consider additional codes for associated pain (e.g., M25.511) or external cause of injury (e.g., W00-Y38) if applicable.