2027 ICD-10-CM Diagnosis Code S46.002SUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder, sequela
S46.002S is a billable ICD-10-CM diagnosis code for unspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder, sequela. The 7th character S marks it as a sequela code, which reports a problem that remains after the original condition has resolved. It is valid on HIPAA claims for fiscal year 2027 (October 1, 2026 through September 30, 2027) and groups to MS-DRG 913 through 914. The code is exempt from POA reporting. Coders also document this condition as injury of left rotator cuff. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Injury, sequela.
Code Identity
Code Classification
Present on Admission (POA)Billing
S46.002S is exempt from POA reporting on inpatient claims to general acute care hospitals. Review the other POA exempt codes in Injuries to the shoulder and upper arm (S40-S49).
Approximate SynonymsGuidance
Alternate terms and clinical phrases that map to this code.
- Injury of left rotator cuff
Coding GuidelinesGuidance
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 applicable episode of care:
- A - initial encounter
- D - subsequent encounter
- S - sequela
Source: ICD-10-CM Official Guidelines for Coding and Reporting, FY 2027, published by CMS and the National Center for Health Statistics.
Instructional NotesGuidance
Instructions from the official ICD-10-CM Tabular List that apply to S46.002S: its own notes plus those printed at S46, block S40-S49, and Chapter 19. A note printed at a category, block or chapter applies to every code under it.
Includes
Further defines, or gives examples of, the content of the category.
- injuries of axilla
- injuries of scapular region
Excludes2
Not included here: the excluded condition is not part of this code, but a patient may have both, so both codes may be reported.
Use Additional Code
Add a second code, after this one, to fully describe the condition.
- code to identify any retained foreign body, if applicable (Z18.-)
Code Also
A second code may be needed to fully describe the condition; the note gives no sequencing direction.
Notes
General instructions on how these codes are used.
- Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code
- The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes.
7th Character
Every code in the category takes a 7th character from the listed values, with the placeholder X filling any empty positions before it.
- The appropriate 7th character is to be added to each code from category S46
- Ainitial encounter
- Dsubsequent encounter
- Ssequela this code
Source: CMS ICD-10-CM Tabular List. How to read instructional notes.
Referenced in Other NotesGuidance
Instructional notes printed at other codes that name S46.002S, its category, or a range that includes it.
Excludes2 2
These codes carry an Excludes2 note naming S46.002S: its condition is not part of those codes, and both may be reported when the patient has both.
Clinical ClassificationClinical
AHRQ’s CCSR groups this code into broader clinical categories.
Patient EducationClinical
Rotator Cuff Injuries
Your rotator cuff is part of your shoulder joint. It's a group of muscles and tendons that holds the top part of your upper arm bone firmly in your shoulder socket. The rotator cuff keeps your shoulder stable when you move your arm in any direction.
The full article covers:
- What is a rotator cuff?
- What are rotator cuff injuries?
- Who is more likely to develop a rotator cuff injury?
- What are the symptoms of rotator cuff injuries?
- How are rotator cuff injuries diagnosed?
- What are the treatments for rotator cuff injuries?
- When should I see a health care provider for shoulder pain?
Read the full article at MedlinePlus
Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.
Convert S46.002S to ICD-9-CMHistory
The closest ICD-9-CM equivalents under the General Equivalence Mappings.
Code HistoryHistory
Questions About S46.002SOverview
Is S46.002S a billable code?
Yes. This is a billable ICD-10-CM code, specific enough to report unspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder, sequela on HIPAA-covered claims from October 1, 2026 through September 30, 2027.
What does the 7th character S in S46.002S mean?
The final character S makes this a sequela code: it reports a lingering problem that remains after the unspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder itself has resolved, not the original event.
What MS-DRG does S46.002S group to?
When unspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder, sequela is the principal diagnosis on an inpatient stay, it groups to MS-DRG 914, 913, with relative weights from 0.9281 to 1.5448 depending on complications. Higher weights mean higher Medicare reimbursement.
Is S46.002S exempt from POA reporting?
Yes. CMS lists this code among those exempt from present on admission reporting, so hospitals do not assign a POA indicator for unspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder, sequela on inpatient claims. The code appears in the Injuries to the shoulder and upper arm (S40-S49) range of the CMS exempt list.
What is the ICD-9 equivalent of S46.002S?
Under the General Equivalence Mappings, unspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder, sequela converts to ICD-9-CM 908.9 (late effect injury NOS). The mapping is approximate, so confirm the match fits the documentation.
