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

This code signifies a muscle, fascia, or tendon strain within the shoulder or upper arm region, where the specific muscle or tendon involved is not documented. It indicates that the patient is receiving follow-up care for an injury that occurred previously, rather than the initial treatment.

Apply this code for subsequent visits related to a shoulder or upper arm strain when the precise anatomical structure affected (e.g., biceps, triceps, deltoid) is not specified in the medical record. This is appropriate for ongoing physical therapy, medication management, or follow-up evaluations after the acute phase of the injury.

• Ensure documentation clearly indicates a "subsequent encounter" for the injury.
• Avoid using this code if a more specific muscle or tendon strain (e.g., rotator cuff, biceps) is documented; use the appropriate specific code instead.
• If the arm affected (left or right) is known, a more specific laterality code should be used.