2024 ICD-10-CM Diagnosis Code S46.919

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

ICD-10-CM Code:
S46.919
ICD-10 Code for:
Strain of unsp musc/fasc/tend at shldr/up arm, unsp arm
Is Billable?
Not Valid for Submission
Code Navigator:

Code Classification

  • Injury, poisoning and certain other consequences of external causes
    (S00–T88)
    • Injuries to the shoulder and upper arm
      (S40-S49)
      • Injury of muscle, fascia and tendon at shoulder and upper arm level
        (S46)

S46.919 is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of strain of unspecified muscle, fascia and tendon at shoulder and upper arm level, unspecified arm. The code is not specific and is NOT valid for the year 2024 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 S46.919 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.

Specific Coding Applicable to Strain of unsp musc/fasc/tend at shldr/up arm, unsp arm

Non-specific codes like S46.919 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10-CM codes with a higher level of specificity when coding for strain of unsp musc/fasc/tend at shldr/up arm, unsp arm:

  • Use S46.919A for initial encounter - BILLABLE CODE

  • Use S46.919D for subsequent encounter - BILLABLE CODE

  • Use S46.919S for sequela - BILLABLE CODE

Approximate Synonyms

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

  • Shoulder strain
  • Strain of muscle of upper arm
  • Strain of shoulder muscle
  • Strain of tendon of upper arm
  • Traumatic tear of tendon of shoulder

Coding Guidelines

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

  • A - initial encounter
  • D - subsequent encounter
  • S - sequela

Patient Education


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 :

  • Tendinitis and bursitis
  • Sprains
  • Dislocations
  • Fractures (broken bones)
  • Nerve problems
  • Osteoarthritis

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:

  • Sprains and strains
  • Dislocations
  • Separations
  • Tendinitis
  • Bursitis
  • Torn rotator cuffs
  • Frozen shoulder
  • Fractures (broken bones)
  • Arthritis

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]

Sprains and Strains

A sprain is a stretched or torn ligament. Ligaments are tissues that connect bones at a joint. Falling, twisting, or getting hit can all cause a sprain. Ankle and wrist sprains are common. Symptoms include pain, swelling, bruising, and being unable to move your joint. You might feel a pop or tear when the injury happens.

A strain is a stretched or torn muscle or tendon. Tendons are tissues that connect muscle to bone. Twisting or pulling these tissues can cause a strain. Strains can happen suddenly or develop over time. Back and hamstring muscle strains are common. Many people get strains playing sports. Symptoms include pain, muscle spasms, swelling, and trouble moving the muscle.

At first, treatment of both sprains and strains usually involves resting the injured area, icing it, wearing a bandage or device that compresses the area, and medicines. Later treatment might include exercise and physical therapy.

NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases


[Learn More in MedlinePlus]

Code History

  • FY 2024 - No Change, effective from 10/1/2023 through 9/30/2024
  • FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
  • FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
  • 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. This was the first year ICD-10-CM was implemented into the HIPAA code set.