S46

Header — not billable

Injury of muscle, fascia and tendon at shoulder and upper arm level

The ICD-10 code for injury of muscle, fascia and tendon at shoulder and upper arm level is S46.

S46 is a non-billable header code. It groups related conditions but cannot be used on its own for reimbursement — select one of the 6 more specific codes below.

Clinical notes

Code also

Two codes may be needed to fully describe a condition, but unlike Code First/Use Additional Code, the sequencing order is not mandated by convention.

any associated open wound (S41.-)

Excludes2 (not included here)

An Excludes2 note means the excluded condition is not part of this one, but a patient can have both at the same time — in that case both codes may be reported together.

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

7th character definitions

These definitions specify what each valid 7th-character value means for codes in this category.

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7th character note

This category requires a 7th character to indicate additional clinical detail (e.g. encounter type: initial, subsequent, sequela). The code is incomplete without it.

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

Documentation support

General coding-documentation guidance — not a substitute for payer-specific requirements or professional coding judgment.

•This is a non-billable header code. Documentation must support a more specific child code before this diagnosis can be reported on a claim.
•This category requires a 7th character. Documentation should clearly indicate the episode of care (initial encounter, subsequent encounter, or sequela).
•As a general rule, code to the highest level of specificity supported by the documentation in the medical record.

S46