CurrentBlue Cross Blue Shield - MassachusettsPolicy 933

Carelon (formerly AIM) Extremity Imaging CPT, HCPCS and Diagnoses Codes

List of CPT, HCPCS and ICD-10 codes in‑scope for Carelon (formerly AIM) Advanced Imaging/Radiology management program for extremity imaging for Commercial and Medicare Advantage products; intended to guide coding and program inclusion but not guarantee member coverage or reimbursement.

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCarelon (formerly AIM) Extremity Imaging CPT, HCPCS and Diagnoses Codes

Policy CodePolicy 933

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionUse the listed CPT/HCPCS and ICD-10 codes to identify in-scope extremity imaging under the Carelon Advanced Imaging/Radiology program and refer to Carelon medical necessity guidelines for coverage decisions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Commercial, Medicare AdvantageProduct lines in-scope

9CPT codes (upper extremity)

manyICD-10 diagnosis codes

includedHealing status modifiers

90-109

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

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Coverage Criteria and In‑Scope Diagnoses

Scope and medical necessity pointer

Codes listed are in-scope under the Carelon Advanced Imaging/Radiology Management Program for specified product lines; medical necessity criteria are addressed in separate Carelon Medical Benefits Management clinical guidelines.

Codes listed are in‑scope for Carelon Advanced Imaging/Radiology Management Program for Commercial Managed Care and Commercial PPO/EPO products, and for Medicare Advantage HMO and PPO products.

Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement; refer to the member's contract benefits and report services using current procedure and diagnosis codes including modifiers where applicable.

Diagnosis code list

ICD-10-CM codes for pathological fractures and related encounter types (upper extremity):

Examples

M84.429K — Pathological fracture, unspecified humerus; subsequent encounter for fracture with nonunion.
M84.429P — Pathological fracture, unspecified humerus; subsequent encounter for fracture with malunion.
M84.431A — Pathological fracture, right ulna; initial encounter for fracture.
M84.431D — Pathological fracture, right ulna; subsequent encounter for fracture with routine healing.
M84.4316 — Pathological fracture, right ulna; subsequent encounter for fracture with delayed healing.

Diagnosis code references

This excerpt enumerates diagnosis codes that are referenced for coverage, claims processing, or documentation purposes within the policy.

ANY of the following

M84.632K — Pathological fracture in other disease, left ulna; subsequent encounter for fracture with nonunion.
S42.001G — Fracture of unspecified part of right clavicle; subsequent encounter for fracture with delayed healing.
S42.001K — Fracture of unspecified part of right clavicle; subsequent encounter for fracture with nonunion.
S41.129D — Laceration with foreign body of unspecified upper arm; subsequent encounter.

ICD-10 fracture code list (partial)

Partial list of ICD-10 diagnosis codes relevant to scapula and humerus fractures and encounter statuses:

ANY of the following

S42.146B/D/K — Nondisplaced fracture of glenoid cavity of scapula, initial or subsequent encounters (routine healing, nonunion).
S42.232A/D/G/K/P/S — 3‑part fracture of surgical neck of humerus (left) with initial and subsequent encounter designators including routine healing, delayed healing, nonunion, malunion, sequela.
S42.239A/B/D/G/K/P — 3‑part fracture of surgical neck of unspecified humerus with initial and subsequent encounter designations including delayed healing and nonunion.

Diagnosis code set

ICD-10 diagnosis codes commonly used when billing for humerus shaft, supracondylar and related humerus fractures (includes laterality and encounter/healing modifiers):

ANY of the following

S42.352A/B/D — Displaced comminuted fracture of shaft of humerus, left arm; initial encounter for closed or open fracture, and subsequent encounter for routine healing.
S42.354A — Nondisplaced comminuted fracture of shaft of humerus, right arm; initial encounter for closed fracture.
S42.361A/B/D/G/K/P/S — Displaced segmental fracture of shaft of humerus, right arm with initial and subsequent encounter designations including routine healing, delayed healing, nonunion, malunion, and sequela.
S42.399D/G/K/P/S — Other fracture of shaft of humerus (unspecified arm) with subsequent encounter designations for routine healing, delayed healing, nonunion, malunion, and sequela.

Diagnosis codes — shoulder and upper arm injuries

Selected ICD-10 codes for shoulder, shoulder girdle and rotator cuff injuries, showing encounter designators where applicable:

ANY of the following

S43.82XA/D — Sprain of other specified parts of shoulder girdle, initial or subsequent encounter.
S43.92XA/D/S — Sprain of unspecified parts of shoulder girdle, with initial, subsequent and sequela designations.
S46.001A/D/S — Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder; initial, subsequent and sequela encounters.

Diagnostic code appendix

ICD-10-CM diagnosis codes for shoulder/upper arm injuries and physeal (Salter‑Harris) fractures included in this appendix:

ANY of the following

S46.899D/S — Other injury of muscles, fascia and tendons at shoulder and upper arm level; subsequent encounter and sequela codes.
S49.001A/D/G/K/P/S — Unspecified physeal fracture of upper end of humerus, with initial and subsequent encounter designators including delayed healing, nonunion, malunion, and sequela.
S49.101A/D/G/K/P/S — Unspecified physeal fracture of lower end of humerus (right), with initial and subsequent encounter designations including routine healing, delayed healing, nonunion, malunion, and sequela.

CPT/HCPCS/ICD-10 Codes and Coding Notes

Upper extremity CT and MRI CPT codesCPT

73200	Computed tomography, upper extremity; without contrast material
73201	Computed tomography, upper extremity; with contrast material(s)
73202	Computed tomography, upper extremity; without contrast, followed by contrast and further sections
73221	MRI upper extremity, any joint, without contrast
73222	MRI upper extremity, any joint, with contrast
73223	MRI upper extremity, any joint, without contrast followed by re-imaging with contrast
73218	MRI upper extremity non-joint, without contrast
73219	MRI upper extremity non-joint, with contrast
73220	MRI upper extremity non-joint (description truncated in source)

Sample of ICD-10 diagnosis codes for extremity conditions (extensive list present)ICD-10

G56.01	Carpal tunnel syndrome, right upper limb
G56.02	Carpal tunnel syndrome, left upper limb
G56.00	Carpal tunnel syndrome, unspecified upper limb
G54.0	Brachial plexus disorders
M19.011	Primary osteoarthritis, right shoulder

ICD-10 codes for upper extremity musculoskeletal and soft tissue disordersICD-10Covered

M65.812	Other synovitis and tenosynovitis, left shoulder (example from list)
M66.111	Rupture of synovium, right shoulder (example from list)
M75.120	Complete rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic (example from list)
M84.311A	Stress fracture, right shoulder, initial encounter (example from list)

Sample ICD-10 codes (upper extremity pathological fractures)ICD-10

M84.429K	Pathological fracture, unspecified humerus, subsequent encounter for fracture with nonunion
M84.431A	Pathological fracture, right ulna, initial encounter for fracture
M84.4316	Pathological fracture, right ulna, subsequent encounter for fracture with delayed healing

Pathological fractures in neoplastic diseaseICD-10

M84.511A	Pathological fracture in neoplastic disease, right shoulder, initial encounter
M84.519A	Pathological fracture in neoplastic disease, unspecified shoulder, initial encounter
M84.521G	Pathological fracture in neoplastic disease, right humerus, subsequent encounter with delayed healing

Pathological fractures (ulna/radius/hand)ICD-10Covered

M84.632K	Pathological fracture in other disease, left ulna, subsequent encounter for fracture with nonunion
M84.633D	Pathological fracture in other disease, right radius, subsequent encounter for fracture with routine healing
M84.634K	Pathological fracture in other disease, left radius, subsequent encounter for fracture with nonunion

Osteomyelitis (acute/subacute/chronic)ICD-10Covered

M86.011	Acute hematogenous osteomyelitis, right shoulder
M86.231	Subacute osteomyelitis, right radius and ulna
M86.311	Chronic multifocal osteomyelitis, right shoulder

Osteonecrosis / aseptic necrosisICD-10Covered

M87.011	Idiopathic aseptic necrosis of right shoulder
M87.131	Osteonecrosis due to drugs of right radius
M87.241	Osteonecrosis due to previous trauma, right hand

Cartilage / osteochondritis disordersICD-10Covered

M93.20	Osteochondritis dissecans of unspecified site
M94.211	Chondromalacia, right shoulder

Periprosthetic fractures and clavicle fracturesICD-10Covered

M97.31XA	Periprosthetic fracture around internal prosthetic right shoulder joint, initial encounter
S42.001G	Fracture of unspecified part of right clavicle, subsequent encounter for fracture with delayed healing
S42.001K	Fracture of unspecified part of right clavicle, subsequent encounter for fracture with nonunion

Imaging/findingsICD-10

R93.6	Abnormal findings on diagnostic imaging of limbs
R93.7	Abnormal findings on diagnostic imaging of other parts of musculoskeletal system

Upper arm wounds/lacerationsICD-10

S41.101A	Unspecified open wound of right upper arm, initial encounter
S41.111A	Laceration without foreign body of right upper arm, initial encounter

Clavicle/scapula/shoulder fractures (examples)ICD-10

S42.001G	Fracture of unspecified part of right clavicle, subsequent encounter for fracture with delayed healing
S42.021A	Displaced fracture of shaft of right clavicle, initial encounter for closed fracture
S42.101A	Fracture of unspecified part of scapula, right shoulder, initial encounter for closed fracture

Scapula and shoulder fracture ICD-10 codes (sample)ICD-10

S42.102K	Fracture of unspecified part of scapula, left shoulder, subsequent encounter for fracture with nonunion
S42.102P	Fracture of unspecified part of scapula, left shoulder, subsequent encounter for fracture with malunion
S42.109A	Fracture of unspecified part of scapula, unspecified shoulder, initial encounter for closed fracture
S42.111A	Displaced fracture of body of scapula, right shoulder, initial encounter for closed fracture
S42.112A	Displaced fracture of body of scapula, left shoulder, initial encounter for closed fracture

Fracture ICD-10 codes (sample)ICD-10Covered

S42.146B	Nondisplaced fracture of glenoid cavity of scapula, unspecified shoulder, initial
S42.151A	Displaced fracture of neck of scapula, right shoulder, initial encounter for closed fracture
S42.152A	Displaced fracture of neck of scapula, left shoulder, initial encounter for closed fracture
S42.201A	Unspecified fracture of upper end of right humerus, initial encounter for closed fracture
S42.211A	Unspecified displaced fracture of surgical neck of right humerus, initial encounter for closed fracture

sample_humerus_fracture_codesICD-10

S42.231S	3-Part Fracture Of Surgical Neck Of Right Humerus, Subsequent Encounter For Fracture With Malunion
S42.232A	3-Part Fracture Of Surgical Neck Of Left Humerus, Initial encounter
S42.239A	3-Part Fracture Of Surgical Neck Of Unspecified Humerus, Initial Encounter For Closed Fracture
S42.241A	4-Part Fracture Of Surgical Neck Of Right Humerus, Initial Encounter For Closed Fracture
S42.251A	Displaced Fracture Of Greater Tuberosity Of Right Humerus, Initial Encounter For Closed Fracture
S42.254A	Nondisplaced Fracture Of Greater Tuberosity Of Right Humerus, Initial Encounter For Closed Fracture
S42.261A	Displaced Fracture Of Lesser Tuberosity Of Right Humerus, Initial Encounter For Closed Fracture
S42.271D	Torus Fracture Of Upper End Of Right Humerus, Subsequent Encounter For Fracture With Routine Healing
S42.291A	Other Displaced Fracture Of Upper End Of Right Humerus, Initial Encounter For Closed Fracture
S42.301A	Unspecified Fracture Of Shaft Of Humerus, Right Arm, Initial Encounter For Closed Fracture

sample humerus shaft and upper-end fracture codesICD-10Covered

S42.296G	Other nondisplaced fracture of upper end of unspecified humerus, subsequent encounter for fracture with delayed healing
S42.296K	Other nondisplaced fracture of upper end of unspecified humerus, subsequent encounter for fracture with nonunion
S42.296P	Other nondisplaced fracture of upper end of unspecified humerus, subsequent encounter for fracture with malunion
S42.296S	Other nondisplaced fracture of upper end of unspecified humerus, sequela
S42.301A	Unspecified fracture of shaft of humerus, right arm, initial encounter for closed fracture
S42.301B	Unspecified fracture of shaft of humerus, right arm, initial encounter for open fracture
S42.301D	Unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with routine healing
S42.301G	Unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with delayed healing
S42.301K	Unspecified fracture of shaft of humerus, right arm, subsequent encounter for fracture with nonunion

sample ICD-10 codes in this excerptICD-10

S42.352A	Displaced comminuted fracture of shaft of humerus, left arm, initial encounter for closed fracture
S42.352B	Displaced comminuted fracture of shaft of humerus, left arm, initial encounter for open fracture
S42.352D	Displaced comminuted fracture of shaft of humerus, left arm, subsequent encounter for fracture with routine healing
S42.354A	Nondisplaced comminuted fracture of shaft of humerus, right arm, initial encounter for closed fracture
S42.361A	Displaced segmental fracture of shaft of humerus, right arm, initial encounter for closed fracture
S42.411A	Displaced simple supracondylar fracture without intercondylar fracture of right humerus, initial encounter for closed fracture

sample ICD-10 codes from sectionICD-10Covered

S42.4226	Displaced comminuted supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for fracture with delayed healing
S42.422K	Displaced comminuted supracondylar fracture without intercondylar fracture of left humerus, subsequent encounter for fracture with nonunion
S42.423A	Displaced comminuted supracondylar fracture without intercondylar fracture of unspecified humerus, initial encounter for closed fracture

Sample ICD-10 codes in this partICD-10

S42.456D	Nondisplaced fracture of lateral condyle of unspecified humerus, subsequent encounter for fracture with routine healing
S42.461A	Displaced fracture of medial condyle of right humerus, initial encounter for closed fracture
S42.471A	Displaced transcondylar fracture of right humerus, initial encounter for closed fracture
S42.481G	Torus fracture of lower end of right humerus, subsequent encounter for fracture with delayed healing
S42.90XA	Fracture of unspecified shoulder girdle, part unspecified, initial encounter for closed fracture
S43.011A	Anterior subluxation of right humerus, initial encounter

Sample ICD-10 codes from sectionICD-10

S43.005D	Unspecified dislocation of left shoulder joint, subsequent encounter
S43.011A	Anterior subluxation of right humerus, initial encounter
S43.024A	Posterior dislocation of right humerus, initial encounter
S43.121A	Dislocation of right acromioclavicular joint; 100%-200% displacement; initial encounter
S43.431A	Superior glenoid labrum lesion of right shoulder, initial encounter
S46.001A	Unspecified injury of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter

Sample codes from sectionICD-10Covered

S43.82XA	Sprain of other specified parts of left shoulder girdle, initial encounter
S46.011A	Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter
S46.111A	Strain of long head of biceps, right arm, initial encounter

Shoulder/upper arm muscle/tendon injury codesICD-10Covered

S46.899D	Other injury of other muscles, fascia and tendons at shoulder and upper arm level; subsequent encounter
S46.901A	Unspecified injury of unspecified muscle, fascia and tendon at shoulder and upper arm level; initial encounter
S46.911A	Strain of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm; initial encounter

Physeal fracture (Salter-Harris) codesICD-10Covered

S49.001A	Unspecified physeal fracture of upper end of humerus, right arm; initial encounter for closed fracture
S49.011A	Salter-Harris type physeal fracture of upper end of humerus, right arm; initial encounter for closed fracture
S49.041A	Salter-Harris type IV physeal fracture of upper end of humerus, right arm; initial encounter for closed fracture

Coverage determination note

Coverage determinationInclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement; refer to the member's contract benefits and use up-to-date procedure, revenue, and diagnosis codes (including modifiers).

Provider reporting requirement

Provider Actions, Documentation & Billing Considerations

Prior Authorization

In-scope Codes & Billing Guidance

The following CPT/HCPCS/ICD codes are in‑scope under the Carelon Advanced Imaging/Radiology Management Program for Commercial and Medicare Advantage products. Inclusion or exclusion of a code does not guarantee member coverage or provider reimbursement — verify the member's contract benefits at the time of service. Providers must report services using current industry-standard procedure and diagnosis codes, including appropriate modifiers.

Applicable to Commercial and Medicare Advantage products
See Carelon Medical Benefits Management Clinical Guidelines for Advanced Imaging/Radiology for medical necessity guidance

Documentation Required

Diagnosis code listing (synovium, tendon)

Diagnosis codes relevant to synovium and tendon disorders, tendon ruptures, and related upper-extremity conditions (examples):

M65.812 — Other synovitis and tenosynovitis, left shoulder

Definitions and Encounter Designators

Coverage implication note

Coverage implication reminderInclusion or exclusion of a code in this document does not constitute or imply member coverage or provider reimbursement; consult the member contract for benefit determinations.

Use current codesProviders must use the most current industry-standard procedure, revenue, and diagnosis codes (including modifiers) when reporting services.

Member-specific determinationCoverage and reimbursement decisions are determined by the member's contract benefits in effect at time of service.

ICD Diagnoses Codes

ICD‑10: synovium/tendon disordersExamples include M65.812 (other synovitis and tenosynovitis, left shoulder), M66.111 (rupture of synovium, right shoulder), and S46.001A (unspecified rotator cuff injury, initial encounter).

Policy Summary

PayerBlue Cross Blue Shield - Massachusetts

PolicyCarelon (formerly AIM) Extremity Imaging CPT, HCPCS and Diagnoses Codes

Policy CodePolicy 933

Change TypeNo material changes

Effective Date

Next Review Date

SourceLink

On This Page

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

Check member benefitsAlways check the member's contract benefits in effect at the time of service to determine coverage or non-coverage for an individual member.

Encounter specificity required

Encounter specificityCodes distinguish initial versus subsequent encounters and include healing-status designators (routine healing, delayed healing, nonunion, malunion, sequela).

Initial encounterSuffix 'A' indicates initial encounter for closed fracture (examples shown for M84.x and S42.x series).

Subsequent encounter variantsSubsequent encounters use suffixes indicating routine (D), delayed (G), nonunion (K), malunion (P), or sequela (S) as applicable to the code series shown.

Anatomic focus

Primary anatomic regionsCodes in this list primarily reference the shoulder, humerus, radius/ulna, wrist/hand, clavicle and related upper‑extremity structures.

Laterality and site modifiersMany codes include laterality (right/left/unspecified) and specific site descriptors (shaft, upper end, lower end, surgical neck, tuberosity, glenoid, etc.).

Related categoriesAlso includes codes for periprosthetic fractures, physeal (Salter‑Harris) fractures, and soft‑tissue/rotator cuff injuries tied to these anatomic regions.

Document scope

Document scopePartial listing of ICD‑10‑CM diagnosis codes relevant to upper extremity injuries, wounds, imaging findings, fractures, and related conditions; intended as a code appendix rather than coverage rules.

Included code typesEntries include fracture classifications, encounter/healing designators, soft‑tissue injuries (rotator cuff, tendon/ muscle strains), wounds/lacerations, edema and abnormal imaging findings.

Physeal fracture appendixPhyseal (Salter‑Harris) fracture codes for the upper end of the humerus are included with multiple encounter/healing modifiers (see S49.x series).

None specified

None specifiedNo additional specification provided in the source for this entry.

M65.821/M65.822/M65.829 — Other synovitis and tenosynovitis, left upper arm/unspecified upper arm

M65.831/M65.839/M65.841/M65.842/M65.849 — Other synovitis and tenosynovitis, left/right forearm/hand/unspecified hand

M66.111–M66.143 — Spontaneous rupture of synovium/tendon, with laterality and unspecified site codes

Documentation Required

ICD-10 diagnoses listing (fracture/nonunion/malunion)

Selected ICD-10 codes for pathological fractures, fractures with delayed healing, nonunion/malunion, and sequelae (humerus/ulna/scapula examples):

M84.429K/P/S — Pathological fracture, unspecified humerus: subsequent encounter with nonunion (K), malunion (P), sequela (S)
M84.431A — Pathological fracture, right ulna, initial encounter
M84.632K — Pathological fracture in other disease, left ulna, subsequent encounter with nonunion
S42.102K — Fracture of unspecified part of scapula, left shoulder, subsequent encounter with nonunion
S42.146A/D/K — Nondisplaced fracture of glenoid cavity of scapula, initial (A), subsequent routine healing (D), subsequent nonunion (K)
S42.296G/K/P/S — Other nondisplaced fracture of upper end of unspecified humerus, subsequent encounter statuses

Documentation Required

ICD-10 diagnosis code list (edema, wounds, imaging findings)

Examples of ICD-10 codes for edema, abnormal imaging findings, wounds and lacerations of the upper arm and related encounter types:

R93.6 — Abnormal findings on diagnostic imaging of limbs
R93.7 — Abnormal findings on diagnostic imaging of other parts of musculoskeletal system
S41.101A/D/S etc. — Unspecified open wound of right upper arm, initial/subsequent/sequela encounters
S41.111A/D/S, S41.112D/S, S41.119A/D/S — Laceration without foreign body of upper arm (right/left/unspecified) with encounter designations
S41.121A/D/S, S41.122D — Laceration with foreign body of right/left upper arm with encounters

Documentation Required

ICD Diagnosis Code Listings (shoulder/scapula)

ICD-10 diagnosis examples for shoulder/scapula fractures and encounter/healing status designations:

S42.102K — Fracture of unspecified part of scapula, left shoulder, subsequent encounter with nonunion
S42.146B/D/K — Nondisplaced fracture of glenoid cavity of scapula, unspecified shoulder: initial (B), subsequent routine healing (D), subsequent nonunion (K)

Documentation Required

ICD-10 humerus fracture code listing

ICD-10 examples for humerus fractures (neck, surgical neck, shaft, supracondylar, condyle) with laterality and encounter types:

S42.231S — 3-part fracture of surgical neck of right humerus, subsequent encounter with malunion (example format)
S42.296G/K/P/S — Other nondisplaced fracture of upper end of unspecified humerus, subsequent encounter with delayed healing/nonunion/malunion/sequela
S42.352A/B/D — Displaced comminuted fracture of shaft of humerus, left arm: initial encounter for closed (A), open (B), subsequent routine healing (D)
S42.4226/G/K/P/S — Displaced comminuted supracondylar fracture without intercondylar fracture of left humerus with various subsequent encounter/healing modifiers

Documentation Required

ICD-10 code list — humerus fractures (condyle/shaft examples)

Examples for lateral condyle and other specified humerus fracture codes and their encounter/healing modifiers:

S42.456D/6/K — Nondisplaced fracture of lateral condyle of unspecified humerus: subsequent encounter with routine healing (D), delayed healing (6), nonunion (K)
Use appropriate laterality and encounter designator (initial A, subsequent D/6/K/P, sequela S) when reporting

Documentation Required

ICD-10 shoulder diagnosis list (dislocation, subluxation, sprain)

Diagnosis codes for dislocations, subluxations, sprains, labral and rotator cuff conditions of the shoulder, including encounter and sequela designations:

S43.005A/D/S, S43.006A/D/S — Unspecified dislocation of left/unspecified shoulder joint with initial/subsequent/sequela encounters
S43.011A/D/S — Anterior subluxation of right humerus, initial/subsequent/sequela
S43.012A/S — Anterior subluxation of left humerus, initial/sequela (examples)
S43.82XA/D — Sprain of other specified parts of left shoulder girdle, initial/subsequent encounter

Documentation Required

ICD codes for unspecified/other injuries & physeal fracture codes and modifiers

ICD-10 codes for other/unspecified muscle, fascia and tendon injuries at shoulder and upper arm level, and examples of physeal (growth plate) fractures with encounter and healing modifiers:

S46.899D/S — Other injury of other muscles, fascia and tendons at shoulder and upper arm level, subsequent/sequela encounters
S46.991A/D/S, S46.992A/D/S, S46.999A/D/S — Other injury of unspecified muscle/fascia/tendon at shoulder/upper arm level with laterality and encounter types
S49.001A/D/G/K/P/S, S49.002A/D/K/P/S, S49.009A/D — Unspecified physeal fracture of upper end of humerus (right/left/unspecified) with initial encounter, subsequent routine healing, delayed healing, nonunion, malunion, sequela

Rotator cuff and biceps strains

Codes for rotator cuff and long head of biceps strains and injuries are listed (S46.x series) with encounter designators.

Extensive soft‑tissue listingsThe document contains numerous soft‑tissue and tendon disorder codes across shoulder, arm, forearm and hand regions (M65–M66, S46 series).

Initial encounter for fracture

Initial encounter definition'Initial encounter' codes (suffix A) identify the first encounter for treatment of a fracture (examples appear in both M84.x and S42.x series).

Code examplesExample entries: M84.431A (pathological fracture, right ulna, initial encounter) and multiple S42.x initial‑encounter humerus/scapula fracture codes.

Usage noteUse initial‑encounter codes to indicate that active treatment is being provided for the fracture during the first encounter.

Subsequent encounter with healing status

Subsequent encounter healing statusSubsequent encounter codes include designators for routine healing (D), delayed healing (G), nonunion (K), malunion (P), and sequela (S).

Examples of categoriesListings show subsequent‑encounter variants across humerus shaft, supracondylar, and other fracture codes indicating routine, delayed, nonunion, malunion, or sequela statuses.

Record the correct statusSelect the appropriate subsequent‑encounter modifier to reflect the fracture’s healing status and encounter context when coding claims.

ICD Diagnoses Codes

Fractures and bone disordersCodes include pathological fractures (M84.x), osteomyelitis (M86.x), and osteonecrosis/aseptic necrosis (M87.x) for upper‑extremity sites.

Examples providedExample: M84.632K (pathological fracture in other disease, left ulna, subsequent encounter with nonunion); M86.011 (acute hematogenous osteomyelitis, right shoulder).

ScopeThese standardized ICD‑10‑CM codes and descriptors cover fractures, infection, and necrosis related to shoulder, humerus, radius/ulna, hand and fingers.

ICD Diagnoses Codes (partial)

Edema and imaging findingsR93.6 and R93.7 are listed for abnormal findings on diagnostic imaging of limbs and other musculoskeletal regions.

Open wounds and lacerationsCodes for unspecified open wounds and lacerations of the upper arm (S41.101A, S41.111A, etc.) are included with encounter designators.

Fracture entriesPartial fracture listings for hand, forearm and upper arm fractures appear alongside soft‑tissue and imaging‑finding codes.

Encounter type / healing status

Encounter classificationsEncounter types include initial encounter (A), subsequent encounter (D) with routine healing, delayed healing (G), nonunion (K), malunion (P), and sequela (S).

Codes use suffixesThe S42.x and related series demonstrate use of encounter/healing suffixes consistently across scapula and humerus fracture codes.

Apply appropriatelyChoose the encounter/healing classification that accurately reflects treatment timing and healing status when assigning codes.

Initial encounter for closed fracture

Initial closed fracture (A)Suffix 'A' denotes initial encounter for closed fracture as shown in multiple S42.x and M84.x entries (e.g., S42.301A).

Initial open fracture (B)Suffix 'B' denotes initial encounter for open fracture in the S42.x series (examples present in listings).

Sequela (S)Suffix 'S' indicates sequela of a fracture (post‑traumatic condition) as used in both pathological fracture and trauma code series.

Subsequent encounter / healing status

Subsequent encounter categoriesSubsequent encounter categories include routine healing (D), delayed healing (G), nonunion (K), malunion (P), and sequela (S) across the listed fracture codes.

Examples across humerus codesNumerous S42.x entries show subsequent‑encounter variants for shaft, upper‑end and supracondylar humerus fractures indicating different healing outcomes.

Claim coding implicationSelecting the correct subsequent category is required to document the patient’s current healing status and support claims processing.

ICD-10 encounter/healing suffixes

Encounter/healing suffixesICD‑10 encounter/healing suffixes are used throughout: A = initial encounter; B = initial encounter for open fracture; D = subsequent encounter with routine healing; G = subsequent encounter with delayed healing; K = subsequent encounter with nonunion; P = subsequent encounter with malunion; S = sequela.

Widespread applicationThese suffixes are applied across pathological fracture (M84.x), traumatic fracture (S42.x), and physeal fracture (S49.x) code groups in this document.

Coding accuracyUse the correct suffix to reflect encounter type and healing status when assigning ICD‑10‑CM codes for upper‑extremity fractures.

encounter/healing status

Encounter timing and contextEncounter types indicate timing and treatment context: initial encounter for closed/open fracture, and subsequent encounter codes reflecting healing status or sequela.

Document examplesThe S42.x humerus and S43.x shoulder listings illustrate initial (A), subsequent (D/G/K/P) and sequela (S) usages tied to treatment context.

Provider actionEnsure clinical documentation supports the encounter type and healing status selected on the claim.

Anatomic and fracture descriptors

Anatomic descriptors and lateralityAnatomic site modifiers indicate right, left, or unspecified humerus and specify locations such as shaft, upper end, lower end, surgical neck, greater/lesser tuberosity, supracondylar and condylar regions.

Fracture descriptorsDescriptors include displaced, nondisplaced, comminuted, segmental, torus, transverse and other specific fracture patterns across S42.x codes.

Coding implicationAssign the code that best matches both anatomic location and fracture descriptor (including laterality) to accurately reflect clinical findings.

Encounter/healing classifications

Encounter/healing classifications listEncounter types used include Initial Encounter (A), Subsequent Encounter (with routine, delayed, nonunion, malunion), and Sequela (S) across fracture code series.

Examples across sectionsSections listing S42.x and related codes consistently show these classifications for humerus and scapula fractures and their outcomes.

Apply to claim codingUse the classification that corresponds to the actual encounter and fracture healing status when submitting claims.

Encounter status and laterality

Encounter status and lateralityCodes include encounter designations (initial A, subsequent D/G/K/P, sequela S) and laterality (right, left, unspecified) as documented across S42.x and S43.x listings.

ExamplesSample entries: S42.471A (displaced transcondylar fracture of right humerus, initial encounter) and S42.456D (nondisplaced lateral condyle fracture, subsequent encounter with routine healing).

Coding accuracySelect codes that reflect both encounter status and laterality to ensure precise clinical and billing representation.

Encounter designators

Encounter designators meaningA = initial encounter; D = subsequent encounter; S = sequela (used consistently in the ICD‑10‑CM codes listed).

Series applicationThese designators are applied throughout the S42.x, S43.x and M84.x code groups in the document to denote timing and post‑treatment status.

Provider guidanceEnsure documentation supports the encounter designator chosen when coding fracture or shoulder/upper‑arm diagnoses.

Encounter designators

Encounter designators usedThe document notes encounter type codes include initial encounter (A), subsequent encounter (D) and sequela (S) across multiple code groups (shoulder, humerus, physeal fractures).

Physeal fracture examplesSalter‑Harris/physeal fracture codes (S49.x) include the same encounter modifiers to indicate initial, subsequent (routine, delayed, nonunion, malunion) and sequela statuses.

Consistency across listsEncounter designators are consistently applied across humerus, shoulder, clavicle and physeal fracture code series.

Salter-Harris / physeal fracture code modifiers

Salter‑Harris (physeal) modifiersSalter‑Harris physeal fracture codes (S49.x) include encounter designations for initial encounter and subsequent encounters with routine healing, delayed healing, nonunion, malunion, and sequela (examples S49.011G/K/P/S and S49.012A/D/G/K/P/S).

Examples providedExamples include S49.011G (Salter‑Harris physeal fracture, right arm, subsequent encounter with delayed healing) and S49.041A (Type IV physeal fracture, right arm, initial encounter).

Coding implicationApply the appropriate encounter/healing suffix to Salter‑Harris codes to reflect the treatment encounter and healing status accurately.