ICD Code S49.91XA

ICD code S49.91XA is an unspecified injury of the right shoulder and upper arm, documented during the patient's initial encounter for this condition.

1. Patient presents with an injury involving the right shoulder and/or upper arm.

2. The specific nature of the injury (e.g., fracture, dislocation, sprain, contusion) cannot be determined or is not documented.

3. The injury is not further specified in terms of type or anatomical detail.

4. This is the patient’s initial encounter for evaluation and treatment of the injury.

5. Laterality is identified as the right side.

Relevant CPT codes that may be used to treat ICD code S49.91XA include:

- 99201–99205 (New patient office or other outpatient visit)

- 99211–99215 (Established patient office or other outpatient visit)

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

- 73060 (Radiologic examination, humerus)

- 23600–23630 (Closed/open treatment of shoulder dislocation)

- 23065–23120 (Incision and drainage, removal of foreign body, or debridement procedures of shoulder/upper arm)

- 23410–23412 (Repair of ruptured musculotendinous cuff, shoulder)

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

- 29805–29828 (Arthroscopy, shoulder, diagnostic and surgical procedures)

- 20552–20553 (Injection(s); single or multiple trigger point(s), one or more muscles)

CPT code selection should be based on the specific clinical scenario and treatment rendered for S49.91XA.

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