Strain of musc/fasc/tend long head of biceps, unsp arm, init

This code signifies a non-traumatic injury to the long head of the biceps muscle, its surrounding fascia, or its tendon, resulting in overstretching or tearing of the fibers. It indicates an acute, initial presentation of this condition affecting an unspecified arm.

Apply this code when a patient presents for the first time with symptoms such as pain, tenderness, or weakness in the anterior shoulder or upper arm, consistent with a biceps strain. This is appropriate for injuries sustained during activities like lifting, throwing, or sudden forceful movements, where the specific arm involved is not documented.

• Ensure documentation clearly states "strain" and specifies the "long head of biceps."
• Only use the "A" seventh character for the initial treatment of the injury.
• Avoid using this code if a specific arm (right or left) is identified in the medical record.