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

This code signifies an acute muscle, fascia, or tendon strain affecting the right shoulder and/or upper arm region. It indicates an initial presentation of the injury, without specification of the particular muscle or tendon involved. The injury is non-traumatic in nature, distinguishing it from a sprain or tear.

Apply this code for patients presenting with a new onset of pain and tenderness in the right shoulder/upper arm, consistent with a muscle strain. This is appropriate when the specific muscle or tendon involved cannot be definitively identified at the initial encounter. Use for injuries like a general "pulled muscle" in the shoulder/upper arm area.

• Ensure the documentation clearly states "strain" and specifies the right side and shoulder/upper arm level.
• Only use for the initial encounter of the injury; subsequent encounters will require a different seventh character.
• Avoid this code if a more specific muscle or tendon is identified, or if the injury is a sprain, tear, or traumatic in nature.