2025 ICD-10-CM code S46.019A

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

Use secondary code(s) from Chapter 20 (External causes of morbidity) to indicate cause of injury, unless the cause is included in the code itself. Use additional code to identify any retained foreign body (Z18.-), if applicable. Do not use this code for birth trauma (P10-P15) or obstetric trauma (O70-O71).

Medical necessity is established by the presence of signs, symptoms, and functional limitations consistent with a rotator cuff strain.The documentation should support the need for diagnostic testing and/or treatment.

Diagnosis is based on patient history, physical exam (especially range of motion), and imaging (X-rays, MRI). Treatment may include ice, rest, pain relievers (NSAIDs, corticosteroids), exercises for flexibility and strength, and possibly surgery for severe cases.

In simple words: This code represents a strain (tear or pull) in the muscles and tendons of your rotator cuff (a group of muscles and tendons in your shoulder), on either the right or left side.This is your first visit to the doctor for this injury.

Strain of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, initial encounter.A rotator cuff strain involves tearing or pulling of the shoulder muscles and tendons that connect muscle to bone, often due to overuse or trauma.This code specifies that the affected shoulder is not identified as right or left and that this is the patient's first encounter for this injury.

Example 1: A patient presents with shoulder pain after falling on an outstretched arm. The physician diagnoses a rotator cuff strain., A baseball pitcher experiences pain and weakness in their shoulder after a game.The physician diagnoses a rotator cuff strain., A patient experiences increasing shoulder pain after repetitive lifting at work. The physician diagnoses a rotator cuff strain.

Documentation should include the patient's history of injury or overuse, physical exam findings (including range of motion and palpation), and results of imaging studies if performed.Since the laterality of the injury is not specified, the documentation should state that the affected shoulder is either unknown or not yet determined.

  • Specialties:Orthopedic Surgery, Sports Medicine, Primary Care
  • Place of Service:Office, Inpatient Hospital, Outpatient Hospital, Emergency Room - Hospital,Other Place of Service
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