2022 ICD-10-CM Code S46.9

Injury of unspecified muscle, fascia and tendon at shoulder and upper arm level

Version 2021

Not Valid for Submission

ICD-10:S46.9
Short Description:Injury of unsp muscle, fascia and tendon at shldr/up arm
Long Description:Injury of unspecified muscle, fascia and tendon at shoulder and upper arm level

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)

S46.9 is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of injury of unspecified muscle, fascia and tendon at shoulder and upper arm level. 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.

Unspecified diagnosis codes like S46.9 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 Injury of unsp muscle, fascia and tendon at shldr/up arm

Non-specific codes like S46.9 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 injury of unsp muscle, fascia and tendon at shldr/up arm:

  • NON-BILLABLE CODE - S46.90 for Unspecified injury of unspecified muscle, fascia and tendon at shoulder and upper arm level
  • NON-BILLABLE CODE - S46.901 for Unspecified injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm
  • BILLABLE CODE - Use S46.901A for initial encounter
  • BILLABLE CODE - Use S46.901D for subsequent encounter
  • BILLABLE CODE - Use S46.901S for sequela
  • NON-BILLABLE CODE - S46.902 for Unspecified injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, left arm
  • BILLABLE CODE - Use S46.902A for initial encounter
  • BILLABLE CODE - Use S46.902D for subsequent encounter
  • BILLABLE CODE - Use S46.902S for sequela
  • NON-BILLABLE CODE - S46.909 for Unspecified injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm
  • BILLABLE CODE - Use S46.909A for initial encounter
  • BILLABLE CODE - Use S46.909D for subsequent encounter
  • BILLABLE CODE - Use S46.909S for sequela
  • NON-BILLABLE CODE - S46.91 for Strain of unspecified muscle, fascia and tendon at shoulder and upper arm level
  • NON-BILLABLE CODE - S46.911 for Strain of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm
  • BILLABLE CODE - Use S46.911A for initial encounter
  • BILLABLE CODE - Use S46.911D for subsequent encounter
  • BILLABLE CODE - Use S46.911S for sequela
  • NON-BILLABLE CODE - S46.912 for Strain of unspecified muscle, fascia and tendon at shoulder and upper arm level, left arm
  • BILLABLE CODE - Use S46.912A for initial encounter
  • BILLABLE CODE - Use S46.912D for subsequent encounter
  • BILLABLE CODE - Use S46.912S for sequela
  • NON-BILLABLE CODE - S46.919 for Strain of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm
  • BILLABLE CODE - Use S46.919A for initial encounter
  • BILLABLE CODE - Use S46.919D for subsequent encounter
  • BILLABLE CODE - Use S46.919S for sequela
  • NON-BILLABLE CODE - S46.92 for Laceration of unspecified muscle, fascia and tendon at shoulder and upper arm level
  • NON-BILLABLE CODE - S46.921 for Laceration of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm
  • BILLABLE CODE - Use S46.921A for initial encounter
  • BILLABLE CODE - Use S46.921D for subsequent encounter
  • BILLABLE CODE - Use S46.921S for sequela
  • NON-BILLABLE CODE - S46.922 for Laceration of unspecified muscle, fascia and tendon at shoulder and upper arm level, left arm
  • BILLABLE CODE - Use S46.922A for initial encounter
  • BILLABLE CODE - Use S46.922D for subsequent encounter
  • BILLABLE CODE - Use S46.922S for sequela
  • NON-BILLABLE CODE - S46.929 for Laceration of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm
  • BILLABLE CODE - Use S46.929A for initial encounter
  • BILLABLE CODE - Use S46.929D for subsequent encounter
  • BILLABLE CODE - Use S46.929S for sequela
  • NON-BILLABLE CODE - S46.99 for Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level
  • NON-BILLABLE CODE - S46.991 for Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm
  • BILLABLE CODE - Use S46.991A for initial encounter
  • BILLABLE CODE - Use S46.991D for subsequent encounter
  • BILLABLE CODE - Use S46.991S for sequela
  • NON-BILLABLE CODE - S46.992 for Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, left arm
  • BILLABLE CODE - Use S46.992A for initial encounter
  • BILLABLE CODE - Use S46.992D for subsequent encounter
  • BILLABLE CODE - Use S46.992S for sequela
  • NON-BILLABLE CODE - S46.999 for Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm
  • BILLABLE CODE - Use S46.999A for initial encounter
  • BILLABLE CODE - Use S46.999D for subsequent encounter
  • BILLABLE CODE - Use S46.999S for sequela

Information for Patients


Arm Injuries and Disorders

Of the 206 bones in your body, three of them are in your arm: the humerus, radius, and ulna. Your arms are also made up of muscles, joints, tendons, and other connective tissue. Injuries to any of these parts of the arm can occur during sports, a fall, or an accident.

Types of arm injuries include

You may also have problems or injure specific parts of your arm, such as your hand, wrist, elbow, or shoulder.


[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)