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S46.991D vs S46.992D

S46.991D (Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm, subsequent encounter) compared with S46.992D (Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, left arm, subsequent encounter), from the official CMS tabular data. S46.991D and S46.992D code the same condition on opposite sides. MedCoder-derived

Relationship

Review

Laterality relationship

S46.991D
Right
Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm, subsequent encounter
S46.992D
Left
Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, left arm, subsequent encounter

Same condition; these differ only in which side is documented.

These codes share a category and title and differ only in the side affected. The documentation decides which applies, and a bilateral code is reported only where the code set provides one.

Source: ICD-10-CM tabular list (laterality variant derived from the code title)

Can these codes be reported together?

Same condition, opposite side. S46.991D and S46.992D name the same condition on opposite sides of the body.

Same category and title, differing only in which side is affected — the documentation decides which one applies, and a bilateral code is reported only where the code set provides one.

Side by side

S46.991DOther injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm, subsequent encounterS46.992DOther injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, left arm, subsequent encounter
Billing statusBillableBillable
ClassificationS00-T88 — Injury, poisoning and certain other consequences of external causesS00-T88 — Injury, poisoning and certain other consequences of external causes
DefinitionOther injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm, subsequent encounter is a billable ICD-10-CM diagnosis code (S46.991D).Other injury of unspecified muscle, fascia and tendon at shoulder and upper arm level, left arm, subsequent encounter is a billable ICD-10-CM diagnosis code (S46.992D).
7th characterThe appropriate 7th character is to be added to each code from category S46The appropriate 7th character is to be added to each code from category S46
Includes
injuries of axilla
injuries of scapular region
injuries of axilla
injuries of scapular region

Derived from the official CMS ICD-10-CM tabular data (FY2026). Not billing advice; verify sequencing rules for the encounter. All data sources