Valid for Submission
S46.002D 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 left shoulder, subsequent encounter. The code S46.002D is valid during the fiscal year 2022 from October 01, 2021 through September 30, 2022 for the submission of HIPAA-covered transactions.
The ICD-10-CM code S46.002D might also be used to specify conditions or terms like injury of left rotator cuff. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.
S46.002D 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 left 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 S46.002D 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.
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:
- A - initial encounter
- D - subsequent encounter
- S - sequela
The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:
- Injury of left rotator cuff
Diagnostic Related Groups - MS-DRG Mapping
Present on Admission (POA)
Convert S46.002D to ICD-9 Code
The General Equivalency Mapping (GEM) crosswalk indicates an approximate mapping between the ICD-10 code S46.002D 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:
- Heat or cold to the sore area
- Medicines that reduce pain and swelling
- Electrical stimulation of muscles and nerves
- Cortisone injection
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
- Sprains and strains
- Torn rotator cuffs
- Frozen shoulder
- Fractures (broken bones)
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]