ICD Code S46.011A

ICD code S46.011A is a diagnosis for a strain of the muscles and tendons in the rotator cuff of the right shoulder, and this code is used for the initial encounter or first visit for this injury.

1. Patient presents with acute pain localized to the right shoulder.

2. Clinical examination reveals tenderness over the rotator cuff region.

3. There is a history of recent trauma, overuse, or sudden movement involving the right shoulder.

4. Physical assessment demonstrates limited range of motion and/or weakness in the right shoulder.

5. Imaging studies (such as MRI or ultrasound) may show evidence of strain or injury to the rotator cuff muscles or tendons.

6. No prior treatment has been initiated for this specific injury (initial encounter).

7. Absence of complete tear or rupture of the rotator cuff.

8. No evidence of chronic or recurrent symptoms; the presentation is acute.

Relevant CPT codes that may be used to treat ICD code S46.011A include:

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

- 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy)

- 29807 (Arthroscopy, shoulder, surgical; repair of SLAP lesion)

- 29827 (Arthroscopy, shoulder, surgical; with rotator cuff repair)

- 23410 (Repair of ruptured musculotendinous cuff, open; acute)

- 23412 (Repair of ruptured musculotendinous cuff, open; chronic)

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

- 97110 (Therapeutic exercises to develop strength and endurance, range of motion and flexibility)

- 97140 (Manual therapy techniques, 1 or more regions, each 15 minutes)

- 99203-99205 (New patient office or other outpatient visit)

- 99213-99215 (Established patient office or other outpatient visit)

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