Is S43.42 a billable ICD-10-CM code?

No. S43.42 is a non-billable header code. Code to a higher level of specificity using one of its child codes.

Where does S43.42 sit in the tabular list?

Injury, poisoning and certain other consequences of external causes (S00-T88), in the block Injuries to the shoulder and upper arm (S40-S49).

What cannot be coded together with S43.42?

S43.42 carries an Excludes1 note, which means the conditions it lists can never be coded together with it on the same encounter.

S43.42

S43.42 — Sprain of rotator cuff capsule

Non-billable headerICD-10-CM

S43.42 is a non-billable header ICD-10-CM code for sprain of rotator cuff capsule. It cannot be billed on its own: choose one of the more specific child codes below. This code also requires a 7th character before it is complete.

This code requires a 7th character

The appropriate 7th character is to be added to each code from category S43

A: initial encounter
D: subsequent encounter
S: sequela

Excludes1 — never code together

These conditions cannot occur together. Billing both on the same encounter is a denial.

rotator cuff syndrome (complete) (incomplete), not specified as traumatic (M75.1-)

Excludes2 — not included here, but may coexist

The excluded condition is not part of this code, but a patient can have both. You may code both.

injury of tendon of rotator cuff (S46.0-)

Risk adjustment

S43.42 does not map to an HCC and does not risk-adjust under CMS-HCC V28. That is normal — most ICD-10 codes do not. It still needs to be coded correctly; it just will not move a RAF score.

Code to one of these instead S43.42

3 child codes. Green means billable.

Related codes at this level

Codes that share S43.4. If S43.42 is not quite right, the correct code is usually one of these.

Questions about S43.42

Is S43.42 a billable ICD-10-CM code?: No. S43.42 is a non-billable header code. Code to a higher level of specificity using one of its child codes.
Where does S43.42 sit in the tabular list?: Injury, poisoning and certain other consequences of external causes (S00-T88), in the block Injuries to the shoulder and upper arm (S40-S49).
What cannot be coded together with S43.42?: S43.42 carries an Excludes1 note, which means the conditions it lists can never be coded together with it on the same encounter.