2026 ICD-10-CM Diagnosis Code S46.009DUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, subsequent encounter

ICD-10-CM Codes›S00–T88›S40-S49›S46

ICD-10-CM S46.009D
CMSSource: CMS FY 2026 ICD-10-CM dataset · Effective Oct 1, 2025 – Sep 30, 2026

S46.009D is a billable ICD-10-CM diagnosis code for unspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, subsequent encounter. The 7th character D marks it as a subsequent encounter code, used during routine care in the healing or recovery phase. It is valid on HIPAA claims for fiscal year 2026 (October 1, 2025 through September 30, 2026) and groups to MS-DRG 949 through 950. The code is exempt from POA reporting. Coders also document this condition as injury of muscle of rotator cuff. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Injury to nerves, muscles and tendons, subsequent encounter.

Code Identity

ICD-10-CM Code
S46.009D
Billable Status
Yes — Valid for Submission
Code Describes
Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, subsequent encounter
Short Description
Unsp inj musc/tend the rotator cuff of unsp shoulder, subs
Parent Code
S46.009
Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder

Code Classification

ChapterS00–T88Injury, poisoning and certain other consequences of external causes
SectionS40-S49Injuries to the shoulder and upper arm
CategoryS46Injury of muscle, fascia and tendon at shoulder and upper arm level
This CodeS46.009DUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, subsequent encounter

Present on Admission (POA)Billing

S46.009D is exempt from POA reporting on inpatient claims to general acute care hospitals. Review other POA exempt codes.

Approximate SynonymsGuidance

Alternate terms and clinical phrases that map to this code.

  • Injury of muscle of rotator cuff
  • Injury of rotator cuff
  • Injury of tendon of the rotator cuff of shoulder

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 2026, published by CMS and the National Center for Health Statistics.

Clinical ClassificationClinical

AHRQ’s CCSR groups this code into broader clinical categories.

CCSR INJ062
Injury to nerves, muscles and tendons, subsequent encounter
Default principal diagnosis: inpatient Yes · outpatient Yes

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 S46.009D to ICD-9-CMHistory

The closest ICD-9-CM equivalents under the General Equivalence Mappings.

ICD-9-CM
V58.89 Other specfied aftercare
Approximate The match is approximate rather than exact.

Code HistoryHistory

FY 2016AddedAdded to the ICD-10-CM code setEffective October 1, 2015, the first year of ICD-10-CM.
FY 2017–2025No changes
FY 2026CurrentCurrent code set, no changesEffective October 1, 2025 through September 30, 2026.

Questions About S46.009DOverview

Is S46.009D 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 unspecified shoulder, subsequent encounter on HIPAA-covered claims from October 1, 2025 through September 30, 2026.

What does the 7th character D in S46.009D mean?

The final character D marks a subsequent encounter: use it for routine care while the unspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder is healing, after active treatment has ended.

What MS-DRG does S46.009D group to?

When unspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, subsequent encounter is the principal diagnosis on an inpatient stay, it groups to MS-DRG 949, 950, with relative weights from 0.6277 to 1.1897 depending on complications. Higher weights mean higher Medicare reimbursement.

Is S46.009D 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 unspecified shoulder, subsequent encounter on inpatient claims.

What is the ICD-9 equivalent of S46.009D?

Under the General Equivalence Mappings, unspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, subsequent encounter converts to ICD-9-CM V58.89 (other specfied aftercare). The mapping is approximate, so confirm the match fits the documentation.

Footnotes

[1] Not chronic - A diagnosis code that does not fit the criteria for chronic condition (duration, ongoing medical treatment, and limitations) is considered not chronic. Some codes designated as not chronic are acute conditions. Other diagnosis codes that indicate a possible chronic condition, but for which the duration of the illness is not specified in the code description (i.e., we do not know the condition has lasted 12 months or longer) also are considered not chronic.