Unsp inj musc/fasc/tend at shldr/up arm, left arm, subs

Unspecified injury of other muscles, fascia and tendons at shoulder and upper arm level, left arm, subsequent encounter

📋Clinical Description

This code signifies an unspecified injury to muscles, fascia, or tendons in the left shoulder or upper arm region. The "unspecified" nature indicates that the precise muscle, fascia, or tendon involved, or the specific type of injury (e.g., strain, tear), is not documented.

🎯When to Use

This code is appropriate for follow-up encounters when a patient is receiving routine care for an unspecific muscle, fascia, or tendon injury of the left shoulder or upper arm. This includes situations like cast changes, removal of external fixation, medication adjustments, or follow-up evaluations during the healing phase.

💡Coding Tips

Ensure the documentation clearly indicates a "subsequent encounter" for the injury.
Only use this code when the specific muscle, fascia, or tendon, and the nature of the injury, are not further specified in the medical record.
If the injury site or type becomes more specific during the subsequent encounter, a more precise code should be used.

AI-generated reference — verify against official guidelines

Code Hierarchy

▲S46.802Unsp injury of musc/fasc/tend at shldr/up arm, left arm

S46.802D(current)

Crosswalks

V58.89ApproxICD-9

Same Category

S46Injury of muscle, fascia and tendon at shldr/up arm S46.0Injury of musc/tend the rotator cuff of shoulder S46.00Unsp injury of musc/tend the rotator cuff of shoulder S46.001Unsp injury of musc/tend the rotator cuff of right shoulder S46.001A