Diseases of the Musculoskeletal System and Connective Tissue

ICD-10 Code: M25.511

Pain in Right Shoulder

Pain in right shoulder without identification of specific underlying pathology, used when pain is the primary complaint and definitive diagnosis cannot be established.

Clinical Information

Shoulder pain is one of the most common musculoskeletal complaints, affecting 18-26% of adults. The shoulder complex involves multiple joints and structures including rotator cuff, bursa, labrum, and surrounding muscles. M25.511 is used for non-specific right shoulder pain when examination and initial workup don't reveal specific pathology. Common etiologies include rotator cuff tendinopathy, subacromial bursitis, adhesive capsulitis, osteoarthritis, labral tears, and referred pain from cervical spine. Initial evaluation includes pain characteristics, range of motion (active/passive), strength testing, special tests (impingement, instability), and neurovascular exam. Treatment is typically conservative initially: NSAIDs, physical therapy, activity modification. Imaging (X-ray, MRI) is ordered based on red flags (trauma, severe functional limitation, night pain) or lack of improvement with conservative management. This code serves as provisional diagnosis pending further workup.

Coding Guidelines

  • 1Use M25.511 for non-specific right shoulder pain when definitive diagnosis cannot be established
  • 2Do NOT use if specific pathology identified: M75.x (rotator cuff), M19.01 (OA), M75.5 (bursitis)
  • 3Laterality required: M25.511 (right), M25.512 (left), M25.519 (unspecified)
  • 4For bilateral pain, code both M25.511 and M25.512
  • 5If pain is referred from cervical spine, use M54.12 (cervical radiculopathy) instead
  • 6Can be used as provisional diagnosis pending imaging or specialist evaluation

Common Uses

  • Primary care visit for right shoulder pain, examination non-specific, X-ray ordered
  • Urgent care for acute right shoulder pain after lifting, no trauma, limited ROM
  • Follow-up for persistent right shoulder discomfort, MRI pending
  • PT initial evaluation for non-specific right shoulder pain
  • Orthopedic consultation showing no definitive pathology, trial of PT
  • Telemedicine visit for right shoulder ache, no red flags

Related ICD-10 Codes

M25.512Pain in left shoulder
M75.100Unspecified rotator cuff tear, right shoulder
M75.51Bursitis of right shoulder
M19.011Primary OA of right shoulder
M75.01Adhesive capsulitis of right shoulder

Documentation Requirements

  • Document 'right shoulder pain' with location (anterior/lateral/posterior)
  • Pain characteristics: onset, duration, severity, aggravating/relieving factors
  • ROM: forward elevation, abduction, rotation, limitations
  • Exam: tenderness, swelling, strength, impingement signs
  • Interventions: imaging ordered, PT referral, medications
  • Why specific diagnosis cannot be made: imaging pending, exam non-diagnostic

Real-World Coding Examples

48-year-old with right shoulder pain x 3 weeks, worse with overhead activities. Exam: full passive ROM, mild pain with active abduction >90°. X-ray ordered. Diagnosis: Pain in right shoulder (M25.511). NSAIDs, PT if no improvement.

Urgent care: right shoulder pain after moving furniture. No trauma. Exam: diffuse tenderness, ROM limited by pain. X-ray negative. Diagnosis: M25.511. Sling, ibuprofen, PCP follow-up.

Orthopedic consult: chronic right shoulder pain. MRI shows minimal changes, no tear. Exam benign. Assessment: Non-specific right shoulder pain (M25.511). PT recommended.

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Medical coding for Diseases of the Musculoskeletal System and Connective Tissue