2021 ICD-10-CM Code S46.001S

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

Version 2021
Billable Code
7th Character Code
Unspecified Code
Sequela Code
MS-DRG Mapping
POA Exempt

Valid for Submission

S46.001S 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, sequela. The code S46.001S is valid during the fiscal year 2021 from October 01, 2020 through September 30, 2021 for the submission of HIPAA-covered transactions.

The ICD-10-CM code S46.001S might also be used to specify conditions or terms like injury of right rotator cuff. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.

S46.001S is a sequela code, includes a 7th character and should be used for complications that arise as a direct result of 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 "sequela" code should be used for chronic or residual conditions that are complications of an initial acute disease, illness or injury. The most common sequela is pain. Usually, two diagnosis codes are needed when reporting sequela. The first code describes the nature of the sequela while the second code describes the sequela or late effect.

Unspecified diagnosis codes like S46.001S 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.

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

Code Classification

Approximate Synonyms

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

Present on Admission (POA)

S46.001S 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 Indicator CodePOA Reason 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 S46.001S to ICD-9 Code

The General Equivalency Mapping (GEM) crosswalk indicates an approximate mapping between the ICD-10 code S46.001S its ICD-9 equivalent. The approximate mapping means there is not an exact match between the ICD-10 code and the ICD-9 code and the mapped code is not a precise representation of the original code.

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:

NIH: National Institute of Arthritis and Musculoskeletal and Skin Disease


[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

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 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 (First year ICD-10-CM implemented into the HIPAA code set)