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

This code signifies an injury to the muscles, fascia, or tendons in the right shoulder or upper arm, where the specific muscle, fascia, or tendon involved is not documented. It indicates that the patient is receiving follow-up care for this previously diagnosed injury.

Use this code for subsequent encounters when the patient is undergoing active treatment, such as physical therapy, wound care, or medication management, for an unspecified right shoulder/upper arm muscle, fascia, or tendon injury. It is appropriate when the initial injury has been diagnosed but the precise anatomical structure affected remains unclarified in the medical record.

• Ensure the documentation clearly states "right arm" and indicates a subsequent encounter for treatment.
• Only use this code when the specific muscle, fascia, or tendon involved is truly unspecified. If more detail is available, a more specific code should be chosen.
• This code is for active treatment; for sequelae (late effects), a different 7th character would be used.