What S46 covers · when clinicians use it
ICD-10 code S46 identifies Injury of muscle, fascia and tendon at shoulder and upper arm level in the U.S. ICD-10-CM clinical and billing record set. It sits within the Injury, Poisoning & External Causes chapter (S00–T88), the section that groups related diagnoses so providers, payers, and public-health agencies report them consistently. Clinicians and medical coders apply S46 when an encounter's findings match the Injury of muscle, fascia and tendon at shoulder and upper arm level description, attaching it to the patient record so downstream insurance claims, payer audits, quality reporting, and epidemiological surveillance all reference the same standardized diagnosis. The ICD-10-CM is maintained by the Centers for Medicare & Medicaid Services and the CDC's National Center for Health Statistics, with an updated official code set released each U.S. fiscal year — always verify S46 against the current CMS/CDC release and your payer's documentation guidance before final use. This page summarizes documentation context for S46 and is a coding reference, not clinical, diagnostic, or billing advice.
ICD10 code S46 represents Injury of muscle, fascia and tendon at shoulder and upper arm level, involving a range of traumatic injuries to the shoulder and upper arm, crucial for accurate diagnosis, orthopedic intervention, and medical coding.
Symptoms
- Bruising, swelling, or abrasions on the shoulder or upper arm – S40
- Open cuts or wounds exposing muscle or bone – S41
- Fractures of clavicle, humerus, or scapula – S42
- Dislocations or ligament sprains affecting the shoulder girdle – S43
- Nerve injuries causing loss of sensation or motor control – S44
- Arterial or venous damage in the upper limb region – S45
- Tears or ruptures of muscles, fascia, or tendons – S46
- Severe crushing trauma to shoulder or arm tissues – S47
- Complete or partial amputation of the upper arm – S48
- Other specified or unspecified injuries of this region – S49
Diagnosis
Evaluation includes physical examination, X-rays for bone injuries, MRI or ultrasound for soft tissue damage, and vascular studies for blood vessel injuries. Timely diagnosis is critical for preserving function.
ICD10 Code Usage
S46 is extensively used in trauma centers, orthopedic practices, rehabilitation services, insurance claims, and medico-legal documentation for injuries involving the shoulder and upper arm.
Related Codes
- S40 – Superficial injury of shoulder and upper arm
- S41 – Open wound of shoulder and upper arm
- S42 – Fracture of shoulder and upper arm
- S43 – Dislocation and sprain of joints and ligaments of shoulder girdle
- S44 – Injury of nerves at shoulder and upper arm level
- S45 – Injury of blood vessels at shoulder and upper arm level
- S47 – Crushing injury of shoulder and upper arm
- S48 – Traumatic amputation of shoulder and upper arm
- S49 – Other and unspecified injuries of shoulder and upper arm
FAQs
Q1: What does ICD10 code S46 mean?
A: It categorizes injuries specifically related to the shoulder and upper arm area.
Q2: How are fractures of the upper arm treated?
A: Depending on severity, treatment may include splinting, surgery, or physiotherapy.
Q3: What are signs of a dislocated shoulder?
A: Intense shoulder pain, inability to move the arm, and visible deformity are common signs.
Q4: Can nerve injuries cause permanent disability?
A: Yes, if not treated promptly, nerve injuries may result in long-term motor or sensory deficits.
Q5: What imaging is best for muscle injuries?
A: MRI provides the best detail for soft tissue injuries including muscles and tendons.
Conclusion
Accurate documentation using ICD10 code S46 is essential for appropriate clinical management, insurance processing, and optimal recovery outcomes following shoulder and upper arm injuries.