Strain of musc/fasc/tend at shldr/up arm, unsp arm, init

This code signifies a non-traumatic overstretching or tearing of muscle fibers, fascia, or tendons in the shoulder or upper arm region, excluding the rotator cuff, biceps, or triceps. It indicates an injury to other, less specifically defined soft tissues in this anatomical area.

Apply this code when documentation specifies a strain of a muscle, fascia, or tendon in the shoulder or upper arm, but does not identify it as a rotator cuff, biceps, or triceps injury. This is appropriate for the initial assessment and treatment of such an injury when the specific muscle or tendon involved is not further detailed.

• Ensure the documentation clearly states "strain" and specifies the shoulder/upper arm level.
• Only use this code when a more specific muscle/tendon (e.g., rotator cuff, biceps, triceps) is not identified.
• The "A" suffix indicates an initial encounter for active treatment of the injury.