ICD-10 Coding for Left Shoulder Strain(S46.012A, S43.422A)
Complete ICD-10-CM coding and documentation guide for Left Shoulder Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Shoulder Strain
S46.0-S46.9Primary Range
Injury of muscle, fascia and tendon at shoulder and upper arm level
This range includes specific codes for strains of the rotator cuff and shoulder capsule.
Sprain and strain of shoulder joint and ligaments
This range includes codes for strains of the shoulder capsule and AC joint.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S46.012A | Strain of muscle(s) and tendon(s) of rotator cuff of left shoulder, initial encounter | Use for initial encounter of rotator cuff strain with confirmed clinical findings. |
|
| S43.422A | Strain of left shoulder capsule, initial encounter | Use for initial encounter of shoulder capsule strain with confirmed clinical findings. |
|
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 left shoulder strain
Essential facts and insights about Left Shoulder Strain
Primary ICD-10-CM Codes for left shoulder strain
Decision Criteria
clinical Criteria
- Positive MRI findings of rotator cuff tear
documentation Criteria
- Detailed mechanism of injury and specific physical exam findings
Applicable To
- Strain of supraspinatus
- Strain of infraspinatus
Excludes
- Sprain of AC joint
Clinical Validation Requirements
- Positive empty can test
- MRI-confirmed partial tear
Code-Specific Risks
- Misclassification as shoulder pain (M25.512)
Coding Notes
- Ensure documentation specifies acute vs chronic and includes mechanism of injury.
S43.422A - Strain of left shoulder capsule, initial encounter
Use for initial encounter of shoulder capsule strain with confirmed clinical findings.
Applicable To
- Strain of shoulder capsule
Excludes
- Rotator cuff strain
Clinical Validation Requirements
- Anterior joint line tenderness
- Positive apprehension/relocation test
Coding Notes
Ensure documentation specifies the specific part of the shoulder affected.
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.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left Shoulder Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S46.012A.
Impact
Clinical: Incomplete clinical picture of the injury., Regulatory: Non-compliance with coding guidelines., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure all incidents leading to injury are documented., Use appropriate external cause codes.
Impact
Reimbursement: Incorrect coding can lead to reduced reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate data representation of patient conditions.
Mitigation Strategy
Use S46.012A for specific rotator cuff strain with documented clinical findings.
Impact
Using general pain codes instead of specific strain codes.
Mitigation Strategy
Educate coding staff on the importance of specificity in coding.
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 Left Shoulder Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Shoulder Strain
Use these documentation templates to ensure complete and accurate documentation for Left Shoulder Strain. These templates include all required elements for proper coding and billing.
Acute traumatic strain
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Pain characteristics
- Functional loss
- Physical exam findings
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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