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    OpenPayerBilling CodesInjuries to the shoulder and upper armICD-10-CM s46-injury-of-muscle-fascia-and-tendon
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    ICD-10-CM Code For Injury Of Muscle Fascia And Tendon At Shoulder And Upper Arm Level: Group Overview

    The International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) code group S46 includes injuries to muscles, fascia, and tendons at the shoulder and upper arm level, such as strains, partial or complete ruptures, and traumatic tears. These ICD-10-CM diagnosis codes are used to document clinical scenarios involving acute trauma or overuse that affect shoulder girdle soft tissues, capturing details like specific structure involved, laterality, and encounter type. Accurate coding within the ICD-10-CM S46 group supports proper claim adjudication, complete clinical documentation, and appropriate reimbursement.

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    ICD-10-CM S46: Injury Of Muscle, Fascia And Tendon At Shoulder And Upper Arm Level Overview

    This group represents injuries to muscles, fascia, and tendons located at the shoulder and upper arm, including strains, ruptures, and traumatic tears. It targets the musculoskeletal structures that support shoulder function and upper arm movement. Accurate coding matters for reimbursement because it captures the specific injured structure, laterality, and encounter type, which affect claim processing and clinical records.

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    When to Use

    Use a code from this group when the clinical record documents an acute or chronic injury to shoulder or upper arm muscles, fascia, or tendons with identified laterality and encounter type. These codes apply for emergency visits, outpatient follow-up, or post-acute care when the injury is the focus of treatment or diagnosis.

    ICD-10-CM Codes

    216 rows

    ICD-10-CM CodeDescription
    S46.001AUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter
    S46.001DUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter
    S46.001SUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, sequela
    S46.002AUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter
    S46.002DUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder, subsequent encounter
    S46.002SUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of left shoulder, sequela
    S46.009AUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, initial encounter
    S46.009DUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, subsequent encounter
    S46.009SUnspecified injury of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, sequela
    S46.011AStrain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter
    S46.011DStrain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter
    S46.011SStrain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, sequela
    S46.012AStrain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, initial encounter
    S46.012DStrain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, subsequent encounter
    S46.012SStrain of muscle(s) and tendon(s) of the rotator cuff of left shoulder, sequela
    S46.019AStrain of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, initial encounter
    S46.019DStrain of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, subsequent encounter
    S46.019SStrain of muscle(s) and tendon(s) of the rotator cuff of unspecified shoulder, sequela
    S46.021ALaceration of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter
    S46.021DLaceration of muscle(s) and tendon(s) of the rotator cuff of right shoulder, subsequent encounter

    Showing 1–20 of 216

    • More pages

    DRG Codes

    14 rows

    DRG CodeDescription
    562Fracture, Sprain, Strain and Dislocation Except Femur, Hip, Pelvis and Thigh with MCC
    563Fracture, Sprain, Strain and Dislocation Except Femur, Hip, Pelvis and Thigh without MCC
    564Other Musculoskeletal System and Connective Tissue Diagnoses with MCC
    565Other Musculoskeletal System and Connective Tissue Diagnoses with CC
    566Other Musculoskeletal System and Connective Tissue Diagnoses without CC/MCC
    604Trauma to the Skin, Subcutaneous Tissue and Breast with MCC
    605Trauma to the Skin, Subcutaneous Tissue and Breast without MCC
    913Traumatic Injury with MCC
    914Traumatic Injury without MCC
    949Aftercare with CC/MCC
    950Aftercare without CC/MCC
    963Other Multiple Significant Trauma with MCC
    964Other Multiple Significant Trauma with CC
    965Other Multiple Significant Trauma without CC/MCC

    Typical Clinical Scenarios

    • An adult presents to the emergency department after falling from a ladder and landing on the outstretched arm with immediate severe lateral shoulder pain, weakness when attempting to lift the arm, and focal tenderness over the rotator cuff region on exam and ultrasound showing an acute tear of the supraspinatus tendon; an acute traumatic muscle/tendon injury at the shoulder/upper arm level is assigned. Typical codes: S46.011A, S46.012A
    • An older patient with progressive shoulder pain and decreased range of motion over months following repetitive overhead activity seeks outpatient orthopedics evaluation; exam and MRI demonstrate chronic degeneration with partial-thickness tendon tear and persistent dysfunction without recent trauma, so a nonacute muscle/tendon injury code from the shoulder/upper arm group is used. Typical codes: S46.011D, S46.012D
    • A patient recovering from shoulder surgery develops late sequelae of prior tendon rupture with ongoing pain, stiffness, and adhesive changes requiring follow-up care and rehabilitation; the encounter documents sequela status of the earlier muscle/tendon injury, and a sequela code from the group is reported to indicate the complication of the prior injury. Typical codes: S46.011S, S46.012S

    Related Codes

    S40-SUPERFICIAL-INJURY-OF-SHOULDER-AND-UPPER-ARM

    ICD-10-CM Code For Superficial Injury Of Shoulder And Upper Arm: Group Overview

    S41-OPEN-WOUND-OF-SHOULDER-AND-UPPER-ARM

    ICD-10-CM Code For Open Wound Of Shoulder And Upper Arm: Group Overview

    S42-FRACTURE-OF-SHOULDER-AND-UPPER-ARM

    ICD-10-CM Code For Fracture Of Shoulder And Upper Arm: Group Overview

    S43-DISLOCATION-AND-SPRAIN-SHOULDER-GIRDLE

    ICD-10-CM Code For Dislocation And Sprain Of Joints And Ligaments Of Shoulder Girdle: Group Overview

    S44-INJURY-OF-NERVES-SHOULDER-UPPER-ARM

    ICD-10-CM Code For Injury Of Nerves At Shoulder And Upper Arm Level: Group Overview

    S45-INJURY-OF-BLOOD-VESSELS-SHOULDER-UPPER-ARM

    ICD-10-CM Code For Injury Of Blood Vessels At Shoulder And Upper Arm Level: Group Overview

    S47-CRUSHING-INJURY-OF-SHOULDER

    ICD-10-CM Code For Crushing Injury Of Shoulder And Upper Arm: Group Overview

    S48-TRAUMATIC-AMPUTATION-SHOULDER-UPPER-ARM

    ICD-10-CM Code For Traumatic Amputation Of Shoulder And Upper Arm: Group Overview

    S49-OTHER-AND-UNSPECIFIED-SHOULDER-INJURIES

    ICD-10-CM Code For Other And Unspecified Injuries Of Shoulder And Upper Arm: Group Overview

    Frequently Asked Questions

    References

    1. 1.CPT® Codes and Descriptions. AAPC. Retrieved Aug 11, 2026.Maintains the CPT code set's official descriptions and guidelines, licensed from the American Medical Association, used as the definitional source for CPT codes on this page.
    2. 2.HCPCS Quarterly Update. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's quarterly release of HCPCS Level II codes and short/long descriptors, the source for HCPCS code definitions and update history.
    3. 3.ICD-10-CM Full Code List. Centers for Medicare & Medicaid Services (CMS). Retrieved Aug 11, 2026.CMS's complete ICD-10-CM diagnosis code list, used to cross-reference diagnosis codes associated with this procedure or service.
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