The ICD-10 code range S90-S99 pertains to injuries to the shoulder and upper arm. These codes are used to document various types of injuries, including fractures, dislocations, sprains, strains, and more. The codes are detailed, allowing for the specification of the exact location of the injury, the nature of the injury, whether it's the initial encounter or a subsequent one, and if the healing process is progressing routinely or there are complications.

Key Usage Points:

•Always use a 7th character extension to specify the encounter type.
•Right and left are distinguished in the fourth character of the code.
•Use additional codes to identify any retained foreign body.
•If a patient is seen for aftercare following injury, assign the acute injury code with the appropriate 7th character.
•For injuries that occur on both arms, assign separate codes for each arm injured.

Coding Guidelines

When to Use:

✓When a patient presents with a fracture of the upper arm.
✓If a patient has a dislocation of the shoulder.
✓In cases of sprains or strains of the shoulder or upper arm.
✓When a patient has an open wound on the shoulder or upper arm.
✓If a patient has an injury of the muscle or tendon of the shoulder or upper arm.

When NOT to Use:

✗Do not use these codes for conditions that are not classified as injuries, such as arthritis or bursitis.
✗Avoid using these codes for injuries to the lower arm or hand.
✗Do not use these codes for chronic conditions, such as tendinitis.
✗Avoid using these codes for congenital anomalies.
✗Do not use these codes for neoplasms of the shoulder or upper arm.

Code Exclusions

Always cross-check the patient's condition with the ICD-10 manual to verify that it falls within the S90-S99 range.

Documentation Requirements

Proper documentation for these codes should include a detailed description of the injury, including the exact location, the nature of the injury, and the encounter type. Documentation should also include any complications or comorbid conditions.

Clinical Information:

•Detailed description of the injury
•Exact location of the injury
•Nature of the injury
•Encounter type
•Any complications or comorbid conditions

Supporting Evidence:

•Medical history
•Physical examination findings
•Imaging studies
•Operative reports if surgery was performed

Good Documentation Example:

Patient presents with a closed fracture of the right humerus, initial encounter. X-ray confirms the diagnosis.

Poor Documentation Example:

Patient has a broken arm.

Common Documentation Errors:

⚠Not specifying the exact location of the injury
⚠Failing to indicate the encounter type
⚠Not documenting any complications or comorbid conditions
⚠Not providing enough detail about the nature of the injury

Range Statistics

Total Codes

Billable

Complexity:

Medium

Primary Use:Clinical Documentation

Chapter:19

Coding Complexity

Medium

Complexity Rating

The complexity of these codes is considered medium because while they require specific details about the injury, they do not require the coder to differentiate between complex medical conditions or treatments.

Key Factors:

▸The need to specify the exact location of the injury
▸The requirement to indicate the encounter type
▸The necessity to document any complications or comorbid conditions
▸The need to provide a detailed description of the injury

Specialty Focus

These codes are most commonly used by orthopedic surgeons and emergency medicine physicians. They may also be used by primary care physicians and hospitalists when treating these injuries.

Primary Specialties:

Orthopedic Surgery

50%

Emergency Medicine

30%

Clinical Scenarios:

• A patient presents to the ER with a dislocated shoulder from a fall.
• A patient is seen in the orthopedic clinic for follow-up of a healing fracture of the upper arm.
• A patient presents to the primary care clinic with an open wound on the shoulder.
• A patient is seen in the hospital for complications of a healing fracture of the upper arm.

Resources & References

There are several resources available for coding injuries to the shoulder and upper arm. These include the official ICD-10 manual, clinical reference materials, and educational resources.

Official Guidelines:

ICD-10-CM Official Guidelines for Coding and Reporting
American Health Information Management Association (AHIMA) guidelines
Centers for Disease Control and Prevention (CDC) guidelines

Clinical References:

American Academy of Orthopaedic Surgeons (AAOS) guidelines
American College of Emergency Physicians (ACEP) guidelines

Educational Materials:

ICD-10-CM Coding Handbook
Medical Coding Pro ICD-10 resources

Frequently Asked Questions

When should a 7th character extension be used?

A 7th character extension should always be used for codes in the S90-S99 range. The extension indicates whether the encounter is initial, subsequent, or a sequela.