2025 ICD-10-CM code S46.012A
(Active) Effective Date: N/A Injury, poisoning and certain other consequences of external causes - Injury to the shoulder and upper arm 19 Feed
Strain of the muscles and tendons of the rotator cuff of the left shoulder.
Medical necessity for the diagnosis and treatment of a rotator cuff strain must be supported by the patient's symptoms, physical examination findings, and imaging results.
Strain of the rotator cuff can present with pain, limited range of motion, bruising, tenderness, swelling, and weakness in the shoulder. Diagnosis typically involves physical examination, assessing range of motion, and imaging studies (X-rays, MRI). Treatment may include rest, ice, pain medication, corticosteroid injections, physical therapy, and potentially surgery for severe cases.
In simple words: This code describes a strain (pulled muscle/tendon) in the rotator cuff of your left shoulder. The rotator cuff is a group of muscles and tendons that help stabilize and move your shoulder.This is for the first time you're seeing a doctor for this particular injury.
Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter.A strain refers to tearing or pulling apart of the muscle fibers of the shoulder and the fibrous tissues (tendons) that connect muscle to bone. This can occur due to overuse or trauma. This code applies to the initial encounter for the injury.
Example 1: A baseball pitcher experiences sudden pain in his left shoulder while throwing a fastball.He is diagnosed with a rotator cuff strain., A painter falls from a ladder and lands on her left shoulder, resulting in a rotator cuff strain., A grocery store worker develops gradual pain and weakness in their left shoulder after repeatedly lifting heavy boxes. The diagnosis is a rotator cuff strain due to overuse.
Documentation should include details of the injury mechanism (e.g., trauma, overuse), location of pain and tenderness, range of motion limitations, results of imaging studies, and any other relevant physical findings.
- Specialties:Orthopedic Surgery, Sports Medicine, Primary Care
- Place of Service:Office, Emergency Room - Hospital, Inpatient Hospital, Outpatient Hospital, Urgent Care Facility