2024 ICD-10-CM Diagnosis Code S46.001D

Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter

ICD-10-CM Code:
S46.001D
ICD-10 Code for:
Unsp inj musc/tend the rotator cuff of r shoulder, subs
Is Billable?
Yes - Valid for Submission
Chronic Condition Indicator: [1]
Not chronic
Code Navigator:

Code Classification

  • Injury, poisoning and certain other consequences of external causes
    (S00–T88)
    • Injuries to the shoulder and upper arm
      (S40-S49)
      • Injury of muscle, fascia and tendon at shoulder and upper arm level
        (S46)

S46.001D is a billable diagnosis code used to specify a medical diagnosis of unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter. The code is valid during the current fiscal year for the submission of HIPAA-covered transactions from October 01, 2023 through September 30, 2024. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

S46.001D is a subsequent encounter code, includes a 7th character and should be used after the patient has completed active treatment for a condition like unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder. According to ICD-10-CM Guidelines a "subsequent encounter" occurs when the patient is receiving routine care for the condition during the healing or recovery phase of treatment. Subsequent diagnosis codes are appropriate during the recovery phase, no matter how many times the patient has seen the provider for this condition. If the provider needs to adjust the patient's care plan due to a setback or other complication, the encounter becomes active again.

Unspecified diagnosis codes like S46.001D are acceptable when clinical information is unknown or not available about a particular condition. Although a more specific code is preferable, unspecified codes should be used when such codes most accurately reflect what is known about a patient's condition. Specific diagnosis codes should not be used if not supported by the patient's medical record.

Approximate Synonyms

The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:

  • Injury of right rotator cuff

Clinical Classification

Coding Guidelines

The appropriate 7th character is to be added to each code from block Injury of muscle, fascia and tendon at shoulder and upper arm level (S46). Use the following options for the aplicable episode of care:

  • A - initial encounter
  • D - subsequent encounter
  • S - sequela

Present on Admission (POA)

S46.001D is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.

CMS POA Indicator Options and Definitions

POA IndicatorReason for CodeCMS will pay the CC/MCC DRG?
YDiagnosis was present at time of inpatient admission.YES
NDiagnosis was not present at time of inpatient admission.NO
UDocumentation insufficient to determine if the condition was present at the time of inpatient admission.NO
WClinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission.YES
1Unreported/Not used - Exempt from POA reporting. NO

Convert S46.001D to ICD-9-CM

  • ICD-9-CM Code: V58.89 - Other specfied aftercare
    Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code.

Patient Education


Rotator Cuff Injuries

What is a rotator cuff?

Your rotator cuff is part of your shoulder joint. It's a group of muscles and tendons that holds the top part of your upper arm bone firmly in your shoulder socket. The rotator cuff keeps your shoulder stable when you move your arm in any direction.

What are rotator cuff injuries?

Rotator cuff injuries are common. Most of them are wear-and-tear injuries from doing the same arm movements over and over - especially reaching over your head. With time, the tissues in the rotator cuff break down, leading to these injuries:

  • Tendinitis. The tendons in the rotator cuff connect your muscles to your shoulder bones. In tendinitis, the tendons become irritated and swollen from being pinched during shoulder movements.
  • Bursitis. The bursa is a small, fluid-filled sac that pads the space between the rotator cuff and the bones of your shoulder. Bursitis happens when the muscle and bone rub the bursa too much. It swells with extra fluid, which causes pain
  • Rotator cuff tears. Tears in a rotator cuff tendon can happen over time or suddenly from an injury, such as falling on an outstretched arm or lifting something heavy. A tear may go part way through a tendon (partial tear) or all the way through (full tear).

Who is more likely to develop a rotator cuff injury?

Anyone can develop a rotator cuff injury. But certain people are more likely to have one:

  • People over age 40. Most rotator cuff injuries are from the wear and tear of aging. By age 80, most adults have tears.
  • Athletes. Playing sports with repeated shoulder movements increases the risk of a rotator cuff injury, for example, tennis, swimming, and baseball - especially pitching.
  • People in jobs that require a lot of reaching overhead or heavy lifting. Carpenters, construction workers, and painters are examples of workers who may be more likely to have rotator cuff problems.

What are the symptoms of rotator cuff injuries?

Rotator cuff injuries don't always cause pain. But when they do, the pain is often in the top part of your arm or shoulder. You may feel more pain when you:

  • Lie down, especially on the injured shoulder
  • Lift your arm or lower it to the front or side
  • Reach behind your back

Other symptoms from a torn rotator cuff may include:

  • Loss of strength in the arm
  • Clicking or popping sounds when you move your arm

How are rotator cuff injuries diagnosed?

To find out if you have a rotator cuff injury, your health care provider:

  • Will examine your shoulder. This includes checking the range of motion and where the pain is.
  • Will test your arm and shoulder strength.
  • May order imaging tests, such as x-rays, an ultrasound, or an MRI scan.

What are the treatments for rotator cuff injuries?

The best treatment for you depends on your age, how much your injury bothers you, and whether your injury was sudden or happened from wear and tear.

Treatments for rotator cuff injuries often include:

  • Rest
  • Putting ice or a cold pack on the sore area
  • Pain relievers to lessen pain and swelling, such as ibuprofen or aspirin
  • Physical therapy exercises to strengthen your shoulder and improve movement
  • A corticosteroid shot into your shoulder joint if other treatments don't help with the pain

Treatments for rotator cuff tendinitis and bursitis may also include ultrasound therapy. Surgery may be an option if your shoulder doesn't feel better in 6 to 12 months.

Treatments for a torn rotator cuff may also include heat to the sore area or electrical stimulation of the nerves and muscles (transcutaneous electrical nerve stimulation, TENS).

You provider may suggest surgery if your tear is large or is from a recent injury, or symptoms last for 6 to 12 months.

When should I see a health care provider for shoulder pain?

If certain activities bother your shoulder, it's best to stop doing them and check with your provider. That's because early treatment can prevent mild rotator cuff injuries from becoming more serious later on. If you your arm feels weak right after a sudden injury to your shoulder, see your provider as soon as possible.


[Learn More in MedlinePlus]

Shoulder Injuries and Disorders

Your shoulder joint is composed of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone). Your shoulders are the most movable joints in your body. They can also be unstable because the ball of the upper arm is larger than the shoulder socket that holds it. To remain in a stable or normal position, the shoulder must be anchored by muscles, tendons, and ligaments.

Because your shoulder can be unstable, it can be easily injured. Common problems include:

  • Sprains and strains
  • Dislocations
  • Separations
  • Tendinitis
  • Bursitis
  • Torn rotator cuffs
  • Frozen shoulder
  • Fractures (broken bones)
  • Arthritis

Health care providers diagnose shoulder problems by using your medical history, a physical exam, and imaging tests.

Often, the first treatment for shoulder problems is RICE. This stands for Rest, Ice, Compression, and Elevation. Other treatments include exercise and medicines to reduce pain and swelling. If those don't work, you may need surgery.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases


[Learn More in MedlinePlus]

Code History

  • FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
  • FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
  • FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
  • FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016. This was the first year ICD-10-CM was implemented into the HIPAA code set.

Footnotes

[1] Not chronic - A diagnosis code that does not fit the criteria for chronic condition (duration, ongoing medical treatment, and limitations) is considered not chronic. Some codes designated as not chronic are acute conditions. Other diagnosis codes that indicate a possible chronic condition, but for which the duration of the illness is not specified in the code description (i.e., we do not know the condition has lasted 12 months or longer) also are considered not chronic.