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2025 ICD-10-CM code S46.011A

Strain of muscles and tendons of the rotator cuff of the right shoulder, initial encounter.

Follow official ICD-10-CM coding guidelines and conventions, ensuring proper sequencing and the addition of secondary codes to fully capture the clinical picture.Always use the most specific code available.Consult your payer's specific guidelines.

Modifiers may be applicable depending on the circumstances of the encounter and services rendered.Review payer specific guidelines for appropriate modifier usage.

Medical necessity for treatment is established through the documentation of symptoms, physical examination findings, and diagnostic imaging confirming the diagnosis of a rotator cuff strain causing significant pain and functional impairment.The severity of the symptoms and the lack of response to conservative treatment (e.g., physical therapy, medication) justify surgical intervention if required.

The clinical responsibility includes obtaining a thorough patient history, conducting a physical examination focusing on range of motion and palpation for tenderness, ordering and interpreting appropriate diagnostic imaging (X-rays, MRI), determining the extent of the injury, and recommending and/or administering appropriate treatment, including conservative measures (rest, ice, NSAIDs, physical therapy) or surgical intervention if necessary.

IMPORTANT:Related codes may include S46.012A (left shoulder),S46.019A (unspecified shoulder), and other codes from chapter S for different types of injuries in the same region, depending on the specifics of the injury.Secondary codes from Chapter 20 (External causes of morbidity) should be used to specify the cause of injury. If a retained foreign body is present, code Z18.- should be added.

In simple words: This code describes the first time a doctor sees you for a pulled or strained muscle or tendon in your right shoulder. This area is called the rotator cuff and helps you move your shoulder.The injury is usually from overuse or an accident.

This code signifies the initial encounter for a strain affecting the muscles and tendons of the rotator cuff in the right shoulder.The rotator cuff is a group of four muscles and their associated tendons surrounding the shoulder joint, crucial for shoulder stability and movement. A strain involves tearing or overstretching of these muscle fibers and/or the tendons connecting them to the bone, often resulting from overuse or trauma.The diagnosis is established through patient history, physical examination (assessing range of motion), and imaging studies like X-rays or MRI.

Example 1: A 45-year-old baseball player experiences sudden pain in his right shoulder while pitching.Examination reveals tenderness and limited range of motion.Diagnosis: S46.011A.Treatment:Rest, ice, NSAIDs, and physical therapy., A 60-year-old woman reports chronic right shoulder pain exacerbated by lifting.MRI confirms a rotator cuff strain. Diagnosis: S46.011A. Treatment: Corticosteroid injection and a course of physical therapy., A 28-year-old construction worker falls from a ladder, injuring his right shoulder.He presents with significant pain, swelling, and limited movement. X-rays rule out fracture. Diagnosis: S46.011A (with secondary code from Chapter 20 specifying the fall as the cause of injury). Treatment:Surgery to repair the torn rotator cuff.

Detailed documentation should include a comprehensive patient history describing the onset, mechanism, and duration of symptoms; the physical examination findings, including range of motion, palpation findings, and observations regarding swelling, bruising, or deformity;results of any imaging studies (X-rays, MRI) performed; and a clear diagnosis of rotator cuff strain in the right shoulder.Treatment plan should also be documented. If surgery is performed, detailed operative notes are required.

** This code is used for the initial encounter. Subsequent encounters should use the appropriate subsequent encounter code.Always verify the code with payer specific guidelines.

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