ICD Code S46.911A

ICD code S46.911A is a medical classification used to denote a strain of an unspecified muscle, fascia, and tendon located at the shoulder and upper arm level on the right arm, specifically for an initial encounter. This code is part of the International Classification of Diseases, 10th Revision (ICD-10), which healthcare providers use to document and bill for diagnoses and treatments related to musculoskeletal injuries. The "initial encounter" designation indicates that this is the first time the patient is being treated for this specific injury.

When considering the use of the ICD code for a strain of unspecified muscle, fascia, and tendon at the shoulder and upper arm level, right arm, initial encounter, healthcare providers should evaluate the following diagnostic criteria and symptoms:

1. Patient History:

• Recent history of physical activity or trauma involving the right shoulder or upper arm.
• Reports of sudden onset of pain following a specific incident or activity.

2. Pain Assessment:

• Localized pain in the right shoulder or upper arm.
• Pain exacerbated by movement or pressure on the affected area.

3. Physical Examination:

• Tenderness upon palpation of the right shoulder or upper arm.
• Swelling or bruising in the affected region.
• Limited range of motion due to pain or discomfort.

4. Functional Impairment:

• Difficulty in performing daily activities that involve the right arm, such as lifting or reaching.
• Weakness in the right shoulder or upper arm.

5. Exclusion of Other Conditions:

• Rule out fractures, dislocations, or other musculoskeletal injuries through imaging or further diagnostic tests if necessary.

6. Initial Encounter:

• This code is specifically used for the initial encounter, indicating that the patient is being seen for the first time for this specific injury.

By following these criteria, healthcare providers can accurately determine when to apply this specific ICD code for billing and documentation purposes.

For the ICD code S46.911A, the relevant CPT codes that may be applicable include:

1. 97110 - Therapeutic exercises to develop strength and endurance, range of motion, and flexibility.

2. 97112 - Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception.

3. 97140 - Manual therapy techniques, such as mobilization/manipulation, manual lymphatic drainage, and manual traction.

4. 97530 - Therapeutic activities, direct (one-on-one) patient contact by the provider, using dynamic activities to improve functional performance.

5. 20552 - Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s).

These CPT codes are commonly used for the treatment of muscle strains and related conditions at the shoulder and upper arm level. It's important to verify the specific treatment plan and services provided to ensure accurate coding and billing.

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