ICD-10 Code for shoulder pain
The ICD-10-CM code for shoulder pain is M25.511 when documented without further specification. Shoulder pain codes to the M25.51- laterality family: M25.511 right, M25.512 left, M25.519 unspecified. The primary lists right shoulder — assign the side the record documents.
Which Code Should You Use?
What to Document
- Laterality — right, left, or unspecified (M25.511/512/519).
- Whether a specific shoulder diagnosis is established (rotator cuff, adhesive capsulitis M75.-, OA).
- Acute injury vs chronic/atraumatic pain.
Common Documentation Pitfalls
- Assigning M25.519 (unspecified) when the note states right or left shoulder.
- Coding the pain symptom when a definitive shoulder diagnosis is documented.
Coding Notes
M25.51- is laterality-driven (right 511 / left 512 / unspecified 519). Assign the documented side rather than the unspecified default, and code a confirmed shoulder diagnosis (rotator cuff, adhesive capsulitis M75.-, OA) instead of the pain symptom.