2026 ICD-10-CM Diagnosis Code S46.109SUnspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm, sequela

ICD-10-CM Codes›S00–T88›S40-S49›S46

ICD-10-CM S46.109S
CMSSource: CMS FY 2026 ICD-10-CM dataset · Effective Oct 1, 2025 – Sep 30, 2026

S46.109S is a billable ICD-10-CM diagnosis code for unspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm, 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 2026 (October 1, 2025 through September 30, 2026) and groups to MS-DRG 913 through 914. The code is exempt from POA reporting. Coders also document this condition as injury of fascia of long head of biceps. In AHRQ's Clinical Classifications Software (CCSR), this diagnosis falls under Injury, sequela.

Code Identity

ICD-10-CM Code
S46.109S
Billable Status
Yes — Valid for Submission
Code Describes
Unspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm, sequela
Short Description
Unsp inj musc/fasc/tend long hd bicep, unsp arm, sequela
Parent Code
S46.109
Unspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm

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 CodeS46.109SUnspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm, sequela

Present on Admission (POA)Billing

S46.109S 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 fascia of long head of biceps
  • Injury of muscle of long head of biceps
  • Injury of tendon of long head of biceps

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 INJ073
Injury, sequela
Default principal diagnosis: inpatient Yes · outpatient Yes

Patient EducationClinical

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.

Read the full article at MedlinePlus

Courtesy of MedlinePlus, a service of the U.S. National Library of Medicine.

Convert S46.109S to ICD-9-CMHistory

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

ICD-9-CM
908.9 Late effect injury NOS
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 S46.109SOverview

Is S46.109S a billable code?

Yes. This is a billable ICD-10-CM code, specific enough to report unspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm, sequela on HIPAA-covered claims from October 1, 2025 through September 30, 2026.

What does the 7th character S in S46.109S mean?

The final character S makes this a sequela code: it reports a lingering problem that remains after the unspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm itself has resolved, not the original event.

What MS-DRG does S46.109S group to?

When unspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm, sequela is the principal diagnosis on an inpatient stay, it groups to MS-DRG 913, 914, with relative weights from 0.8855 to 1.6346 depending on complications. Higher weights mean higher Medicare reimbursement.

Is S46.109S 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, fascia and tendon of long head of biceps, unspecified arm, sequela on inpatient claims.

What is the ICD-9 equivalent of S46.109S?

Under the General Equivalence Mappings, unspecified injury of muscle, fascia and tendon of long head of biceps, unspecified arm, sequela converts to ICD-9-CM 908.9 (late effect injury NOS). 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.