ICD Code S43.402A

ICD code S43.402A is an unspecified sprain of the left shoulder joint, initial encounter.

1. Patient presents with pain, swelling, or tenderness in the left shoulder following trauma or injury

2. Physical examination reveals decreased range of motion or instability in the left shoulder

3. No evidence of fracture or dislocation on imaging studies

4. Clinical assessment does not specify the exact ligament or structure involved in the sprain

5. This is the patient’s first visit for evaluation and treatment of this specific injury

Relevant CPT codes that may be used to treat ICD code S43.402A include:

- 99201–99205 (Office or other outpatient visit, new patient)

- 99211–99215 (Office or other outpatient visit, established patient)

- 73030 (Radiologic examination, shoulder; complete, minimum of two views)

- 73060 (Radiologic examination, shoulder; single view)

- 20552 (Injection(s); single or multiple trigger point(s), one or two muscle(s))

- 20610 (Arthrocentesis, aspiration and/or injection; major joint or bursa)

- 97110 (Therapeutic exercises)

- 97140 (Manual therapy techniques)

- 97010 (Application of a modality to 1 or more areas; hot or cold packs)

- 97035 (Ultrasound, each 15 minutes)

- 99281–99285 (Emergency department visit, if applicable)

CPT code selection should be based on the specific services provided for S43.402A.

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