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S46.911Non-billableSave

S46.911 - Strain of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm

ICD-10-CM Chapter 19: Injury, poisoning and certain other consequences of external causes · S40-S49 Injuries to the shoulder and upper arm (S40-S49) · Subcategory of S46.91 · FY2027

Coding Guidance

S46.911 requires a 7th character. Report the code below that matches the documentation, for example A for initial encounter, D for subsequent encounter, S for sequela.

7th Character

The appropriate 7th character is to be added to each code from category S46

Includes, Excludes and Coding Notes

Excludes 2 — Not Included HereFrom S46

Not part of this code; report both codes when the patient has both conditions.

  • injury of muscle, fascia and tendon at elbow (S56.-)
  • sprain of joints and ligaments of shoulder girdle (S43.9)
Code AlsoFrom S46

Report an additional code when both conditions apply.

  • any associated open wound (S41.-)
IncludesFrom S40-S49 Injuries to the shoulder and upper arm (S40-S49)

Conditions this code covers.

  • injuries of axilla
  • injuries of scapular region
Excludes 2 — Not Included HereFrom S40-S49 Injuries to the shoulder and upper arm (S40-S49)

Not part of this code; report both codes when the patient has both conditions.

  • burns and corrosions (T20-T32)
  • frostbite (T33-T34)
  • injuries of elbow (S50-S59)
  • insect bite or sting, venomous (T63.4)
Excludes 2 — Not Included HereFrom Chapter S00-T88

Not part of this code; report both codes when the patient has both conditions.

  • birth trauma (P10-P15)
  • obstetric trauma (O70-O71)
Use Additional CodeFrom Chapter S00-T88

Add a secondary code to identify the associated condition or cause when it is documented.

  • code to identify any retained foreign body, if applicable (Z18.-)
NotesFrom Chapter S00-T88

Instructional notes from the ICD-10-CM tabular list.

  • Use secondary code(s) from Chapter 20, External causes of morbidity, to indicate cause of injury. Codes within the T section that include the external cause do not require an additional external cause code
  • The chapter uses the S-section for coding different types of injuries related to single body regions and the T-section to cover injuries to unspecified body regions as well as poisoning and certain other consequences of external causes.

More Specific Codes (3)

S46.911AStrain of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm, initial encounter→S46.911DStrain of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm, subsequent encounter→S46.911SStrain of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm, sequela→

Related condition guides

Documentation requirements, coding pitfalls and FAQs for conditions coded with S46.911.