2025 ICD-10-CM code S40
Superficial injury of the shoulder and upper arm.
Medical necessity is determined by the severity of the injury and the need for medical intervention to prevent complications such as infection.
Providers diagnose the condition based on the patient’s history and physical exam. Treatment options include pain relievers, antibiotics to prevent infection, cleaning and bandaging the wound, and surgery if necessary.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the shoulder and upper arm (S40-S49)
In simple words: A minor scrape or cut on your shoulder or upper arm, causing little to no bleeding or swelling. This could happen from a fall, accident, or even during surgery.
Superficial injury of the shoulder and upper arm involves a minimal scrape or wound with minimal, if any, bleeding or swelling of the affected area due to a fall, accident, or surgery.
Example 1: A patient falls and scrapes their upper arm, resulting in a minor abrasion., During a surgical procedure on the shoulder, a small superficial incision is made., A patient sustains a minor cut on their shoulder during a car accident.
Documentation should include the cause of the injury, the location and size of the wound, the presence or absence of bleeding and swelling, and any treatment provided.
** Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71). Excludes2: burns and corrosions (T20-T32), frostbite (T33-T34), injuries of elbow (S50-S59), insect bite or sting, venomous (T63.4). Use additional code to identify any retained foreign body, if applicable (Z18.-).
- Specialties:Primary Care, Emergency Medicine, General Surgery
- Place of Service:Office, Home, Inpatient Hospital, On Campus-Outpatient Hospital, Emergency Room - Hospital, Outpatient Hospital