ICD-10 Coding for Shoulder Strain(S46.011A, S46.012A)
Complete ICD-10-CM coding and documentation guide for Shoulder Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Shoulder Strain
S46.0-S46.9Primary Range
Injury of muscle and tendon at shoulder and upper arm level
This range includes codes for traumatic injuries to the shoulder muscles and tendons, including strains.
Shoulder lesions
This range includes codes for non-traumatic shoulder conditions that may be considered in differential diagnosis.
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 right shoulder rotator cuff strains during the initial encounter. |
|
| S46.012A | Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter | Use for acute traumatic left shoulder rotator cuff strains during the initial encounter. |
|
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 shoulder strain
Essential facts and insights about Shoulder Strain
Primary ICD-10-CM Codes for shoulder strain
Decision Criteria
clinical Criteria
- Acute onset with a clear traumatic event
documentation Criteria
- Detailed physical exam and imaging findings
Applicable To
- Acute traumatic right rotator cuff strain
Excludes
- Non-traumatic rotator cuff tear (M75.121)
Clinical Validation Requirements
- Mechanism of injury (e.g., fall)
- Physical exam findings (e.g., positive Hawkins' sign)
- Imaging results (e.g., MRI showing partial tear)
Code-Specific Risks
- Incorrect laterality documentation
- Missing encounter type
Coding Notes
- Ensure documentation includes the mechanism of injury and laterality.
S46.012A - Strain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter
Use for acute traumatic left shoulder rotator cuff strains during the initial encounter.
Applicable To
- Acute traumatic left rotator cuff strain
Excludes
- Non-traumatic rotator cuff tear (M75.122)
Clinical Validation Requirements
- Mechanism of injury (e.g., weightlifting)
- Physical exam findings (e.g., painful arc)
- Imaging results (e.g., MRI showing partial tear)
Coding Notes
Ensure documentation includes the mechanism of injury and laterality.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Unspecified fall, initial encounter
W19.XXXADifferential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Complete rotator cuff tear or rupture of right shoulder, not specified as traumatic
M75.121Complete rotator cuff tear or rupture of left shoulder, not specified as traumatic
M75.122Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Shoulder 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: Inadequate information for treatment planning., Regulatory: Non-compliance with documentation standards., Financial: Potential for claim denials or reduced reimbursement.
Mitigation Strategy
Use specific terms and include detailed findings., Ensure laterality and mechanism of injury are documented.
Impact
Reimbursement: Claims may be denied or delayed., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate patient records and statistics.
Mitigation Strategy
Verify and document the correct side of the body affected.
Impact
Reimbursement: Incomplete claims may affect payment., Compliance: Failure to meet coding standards., Data Quality: Incomplete injury data for analysis.
Mitigation Strategy
Always include an external cause code for traumatic injuries.
Impact
Incorrect documentation or coding of the affected side.
Mitigation Strategy
Implement double-check systems for laterality in documentation and 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 Shoulder Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Shoulder Strain
Use these documentation templates to ensure complete and accurate documentation for Shoulder Strain. These templates include all required elements for proper coding and billing.
Acute Traumatic Shoulder Strain
Specialty: OrthopedicsRequired Elements
- Mechanism of injury
- Laterality
- Physical exam findings
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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