2021 ICD-10-CM Code S46.909

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

Version 2021
Non-Billable Code
Unspecified Code

Not Valid for Submission

S46.909 is a "header" nonspecific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of unspecified injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm. The code is NOT valid for the year 2021 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 S46.909 might also be used to specify conditions or terms like injury of fascia at shoulder level, injury of fascia at upper arm level, injury of multiple muscles and tendons at shoulder and upper arm level, injury of muscle at shoulder level, injury of muscle at upper arm level , injury of tendon at shoulder level, etc.

Unspecified diagnosis codes like S46.909 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:S46.909
Short Description:Unsp injury of unsp musc/fasc/tend at shldr/up arm, unsp arm
Long Description:Unspecified injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm

Code Classification

Specific Coding for Unsp injury of unsp musc/fasc/tend at shldr/up arm, unsp arm

Header codes like S46.909 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 unsp musc/fasc/tend at shldr/up arm, unsp arm:

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


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)