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

This code signifies a follow-up visit for an injury to an unspecified muscle, fascia, or tendon in the left shoulder or upper arm. The exact nature or location of the soft tissue injury within this region is not documented.

Apply this code when a patient presents for ongoing care, such as physical therapy, follow-up imaging, or medication management, for a previously diagnosed but unspecified soft tissue injury of the left shoulder/upper arm. This is appropriate when the initial injury's specific muscle, fascia, or tendon involvement was not or cannot be precisely identified.

• Only use this code for subsequent encounters; an initial encounter would use the 'A' seventh character.
• Avoid this code if a more specific muscle, fascia, or tendon injury (e.g., rotator cuff tear, biceps tendon strain) is documented.
• Query the provider for more specific documentation if possible to allow for a more precise code selection.