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

This code signifies a chronic or late-effect condition resulting from a previous strain injury to muscles, fascia, or tendons in the shoulder or upper arm region. It indicates that the initial acute injury has resolved, but the patient continues to experience residual symptoms or complications directly attributable to that past strain. The specific arm affected is not documented.

Apply this code when documentation clearly states a patient is presenting for follow-up or treatment of persistent issues (e.g., chronic pain, weakness, limited range of motion) stemming from a previously diagnosed strain of an unspecified muscle, fascia, or tendon in the shoulder or upper arm. This code is appropriate when the initial injury is no longer acute and the current encounter addresses its long-term consequences.

• Always use this code as a secondary diagnosis, following the code for the specific residual condition (e.g., chronic pain).
• Ensure documentation explicitly links the current symptoms to a past strain injury.
• Avoid using this code for acute or subacute strain injuries; those require an initial encounter or subsequent encounter code.