ICD-10 Coding for Shoulder Muscle Strain(S46.011A, S46.012A)
Complete ICD-10-CM coding and documentation guide for Shoulder Muscle Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Shoulder Muscle Strain
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S46.011A | Strain of right rotator cuff muscles/tendons, initial encounter | Use for initial encounter of acute right shoulder strain due to trauma. |
|
| S46.012A | Strain of left rotator cuff muscles/tendons, initial encounter | Use for initial encounter of acute left shoulder strain due to trauma. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for right shoulder muscle strain
Essential facts and insights about Shoulder Muscle Strain
Primary ICD-10-CM Codes for shoulder muscle strain
Decision Criteria
clinical Criteria
- Acute pain following a specific injury mechanism
documentation Criteria
- Documented laterality and encounter type
Applicable To
- Acute strain of right rotator cuff
Excludes
- Chronic rotator cuff tear (M75.1-)
Clinical Validation Requirements
- Acute onset following a specific traumatic event
- Physical exam findings such as pain with specific shoulder tests
- Imaging showing muscle edema without full-thickness tear
Code-Specific Risks
- Confusing with chronic conditions
- Omitting laterality
Coding Notes
- Ensure documentation specifies laterality and encounter type.
S46.012A - Strain of left rotator cuff muscles/tendons, initial encounter
Use for initial encounter of acute left shoulder strain due to trauma.
Applicable To
- Acute strain of left rotator cuff
Excludes
- Chronic rotator cuff tear (M75.1-)
Clinical Validation Requirements
- Acute onset following a specific traumatic event
- Physical exam findings such as pain with specific shoulder tests
- Imaging showing muscle edema without full-thickness tear
Coding Notes
Ensure documentation specifies laterality and encounter type.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Chronic rotator cuff tear
M75.11Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Shoulder Muscle Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S46.011A.
Impact
Clinical: May lead to incorrect diagnosis and treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.
Mitigation Strategy
Always ask and document how the injury occurred., Use structured templates to ensure completeness.
Impact
Reimbursement: May lead to claim denials or reduced reimbursement., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Always use specific codes for right or left shoulder when laterality is known.
Impact
Failure to document laterality can lead to incorrect coding.
Mitigation Strategy
Implement mandatory fields in EHR for laterality.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Shoulder Muscle Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Shoulder Muscle Strain
Use these documentation templates to ensure complete and accurate documentation for Shoulder Muscle Strain. These templates include all required elements for proper coding and billing.
Initial encounter for traumatic shoulder strain
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Laterality
- Specific muscle involvement
- Functional impact
- Imaging findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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