2022 ICD-10-CM Code S46.002

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

Version 2021

Not Valid for Submission

ICD-10:S46.002
Short Description:Unsp injury of musc/tend the rotator cuff of left shoulder
Long Description:Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder

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)

S46.002 is a non-specific and non-billable diagnosis 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 left shoulder. The code is not specific and is NOT valid for the year 2022 for the submission of HIPAA-covered transactions. Category or Header define the heading of a category of codes that may be further subdivided by the use of 4th, 5th, 6th or 7th characters.

The ICD-10-CM code S46.002 might also be used to specify conditions or terms like injury of left rotator cuff.

Unspecified diagnosis codes like S46.002 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.

Coding Guidelines

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

Specific Coding for Unsp injury of musc/tend the rotator cuff of left shoulder

Non-specific codes like S46.002 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10 codes with a higher level of specificity when coding for unsp injury of musc/tend the rotator cuff of left shoulder:

  • BILLABLE CODE - Use S46.002A for initial encounter
  • BILLABLE CODE - Use S46.002D for subsequent encounter
  • BILLABLE CODE - Use S46.002S for sequela

Approximate Synonyms

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