ICD-10 Code S46.001

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

Version 2019 Non-Billable Code

Not Valid for Submission

S46.001 is a "header" nonspecific and non-billable code code, consider using a code with a higher level of specificity for a diagnosis of unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder. The code is NOT valid for the year 2020 for the submission of HIPAA-covered transactions.

ICD-10: S46.001
Short Description:Unsp injury of musc/tend the rotator cuff of right shoulder
Long Description:Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder

Consider the following ICD-10 codes with a higher level of specificity:

  • S46.001A - Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter
  • S46.001D - Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter
  • S46.001S - Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, sequela

Code Classification

  • Injury, poisoning and certain other consequences of external causes (S00–T98)
    • Injuries to the shoulder and upper arm (S40-S49)
      • Injury of muscle, fascia and tendon at shldr/up arm (S46)

Code History

  • FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016
    (first year ICD-10-CM implemented into the HIPAA mandated code set)
  • FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
  • FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
  • FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
  • FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020

Information for Medical Professionals

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

Information for Patients


Rotator Cuff Injuries

Your rotator cuff is located in your shoulder area. It is made of muscles and tendons. It helps your shoulder to move and stay stable. Problems with the rotator cuff are common. They include tendinitis, bursitis, and injuries such as tears.

Rotator cuff tendons can become inflamed from frequent use or aging. Sometimes they are injured from a fall on an outstretched hand. Sports or jobs with repeated overhead motion can also damage the rotator cuff. Aging causes tendons to wear down, which can lead to a tear.

Some tears are not painful, but others can be very painful. Treatment for a torn rotator cuff depends on age, health, how severe the injury is, and how long you've had the torn rotator cuff.

Treatment for torn rotator cuff includes:

  • Rest
  • Heat or cold to the sore area
  • Medicines that reduce pain and swelling
  • Electrical stimulation of muscles and nerves
  • Ultrasound
  • Cortisone injection
  • Surgery

NIH: National Institute of Arthritis and Musculoskeletal and Skin Disease


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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
  • 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


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ICD-10 Footnotes

General Equivalence Map Definitions
The ICD-10 and ICD-9 GEMs are used to facilitate linking between the diagnosis codes in ICD-9-CM and the new ICD-10-CM code set. The GEMs are the raw material from which providers, health information vendors and payers can derive specific applied mappings to meet their needs.

  • Approximate Flag - The approximate flag is on, indicating that the relationship between the code in the source system and the code in the target system is an approximate equivalent.
  • No Map Flag - The no map flag indicates that a code in the source system is not linked to any code in the target system.
  • Combination Flag - The combination flag indicates that more than one code in the target system is required to satisfy the full equivalent meaning of a code in the source system.