ICD-10 Coding for Right Shoulder Trauma(S46.011A, S42.011A)
Complete ICD-10-CM coding and documentation guide for Right Shoulder Trauma. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Shoulder Trauma
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 muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter | Use for acute traumatic injuries to the rotator cuff of the right shoulder. |
|
| S42.011A | Fracture of clavicle, right, initial encounter | Use for acute fractures of the right clavicle confirmed by imaging. |
|
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 trauma
Essential facts and insights about Right Shoulder Trauma
Primary ICD-10-CM Codes for right shoulder trauma
Decision Criteria
clinical Criteria
- Presence of traumatic event leading to shoulder pain
documentation Criteria
- Detailed description of the mechanism of injury
Applicable To
- Acute traumatic rotator cuff strain
Excludes
- Non-traumatic rotator cuff tear (M75.111)
Clinical Validation Requirements
- Documented traumatic mechanism (e.g., fall onto outstretched arm)
- Positive Hawkins/Kennedy test
- MRI showing edema but no full-thickness tear
Code-Specific Risks
- Confusing with non-traumatic conditions
- Incorrect 7th character for encounter type
Coding Notes
- Ensure documentation specifies the traumatic nature and laterality of the injury.
S42.011A - Fracture of clavicle, right, initial encounter
Use for acute fractures of the right clavicle confirmed by imaging.
Applicable To
- Acute fracture of right clavicle
Excludes
- Pathological fracture (M84.411A)
Clinical Validation Requirements
- X-ray confirmation of fracture
- Documented traumatic mechanism
Coding Notes
Ensure imaging confirms the fracture and document the specific location.
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 Right Shoulder Trauma to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S46.011A.
Impact
Clinical: Leads to ambiguity in treatment plans., Regulatory: Non-compliance with ICD-10 coding standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Always document 'right' or 'left' in the assessment., Use templates that prompt for laterality.
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use S46.011A for traumatic injuries with specific mechanism documented.
Impact
Use of unspecified codes can trigger audits.
Mitigation Strategy
Ensure documentation specifies laterality and encounter type.
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 Right Shoulder Trauma, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Shoulder Trauma
Use these documentation templates to ensure complete and accurate documentation for Right Shoulder Trauma. These templates include all required elements for proper coding and billing.
Acute Right Shoulder Trauma in Emergency Department
Specialty: Emergency MedicineRequired Elements
- Mechanism of injury
- Physical exam findings
- Imaging results
- Diagnosis
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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