Left Shoulder Pain ICD 10: M25.512 Coding Guide

The ICD-10-CM code for left shoulder pain is M25.512. Use this code when the cause for left shoulder pain is not documented. This could be applicable to cases of diagnosed shoulder pain that do not describe the cause of the pain.

The more difficult choice is between using the symptom code, a confirmed shoulder condition code, and a code to describe pain. A billing drop down list will not resolve this. The assessment, purpose of the encounter, and coding instructions will determine the appropriate code assignment.

Use the tables below to locate the applicable code, and review the documentation examples, rules and submission requirements before submitting a claim.

Left Shoulder Pain ICD 10: Quick Reference

These codes describe different findings. Select the entry supported by the record; the table is not a list of diagnoses to add together.

Code descriptors should be checked in the official CDC/NCHS Alphabetic Index and Tabular List. Select the release applicable to the encounter, including its instructional notes. 

M25.512 and the Diagnosis Documented

M25.512, found under M25.51, pain in shoulder, within the chapter on the musculoskeletal system, is a standalone code. M25.51 is a parent category that demands a more detailed code, of which M25.512 is not. An injury encounter extension (IEE) such as A, D or S, is also not applicable to M25.512.

“Arthralgia” is joint pain. Thus, documented left shoulder arthralgia will lead to code M25.512, via the Index. It does not indicate or prove the existence of arthritis, a tendon tear, or another structural diagnosis.

It may be considered appropriate to use a symptom code

If the cause of the encounter is not established, an appropriate symptom code could describe the encounter. M25.512 can be applied beyond the first visit if the provider continues to document left shoulder pain, but without a definitive diagnosis. This code is not automatically incorrect if they have a referral, imaging order, or pending test.

If there is no confirmed condition, AAFP coding guidance encourages reporting of the documented symptom. Any diagnosis that is suspected and included in the differential should be reported as suspected (not established). The process of assessing the pain in the left shoulder that may occur with a bursitis is different from confirming the left shoulder bursitis.

Claims should be based on a provider’s actual assessment of a patient’s symptoms, not on the list of symptoms, and a clear Physicians Billing Process should differentiate documented symptoms from confirmed diagnoses.

Coding for confirmed conditions

When pain is associated with and explained by the condition that is documented and confirmed, the symptom code may no longer be appropriate. However, pain may be classified with the condition and diagnosed together. If the classification directs that symptom codes not be used with the condition code, then the symptom code may still be reported.

Review the assessment for each encounter. A problem list that is rolled forward may result in an unsupported symptom code being reported on the claim, or may retain a diagnosed condition that no longer reflects the services provided.

A useful record review includes the following three steps:

• Which conditions or symptoms did the provider establish?
• Which problems were assessed, treated, or otherwise were relevant to the encounter?
• Which codes and instructions address the above problems?

This sequence also can keep a search for a payable diagnosis from replacing a clinical review of the record.

Laterality: Left, Right, Both, or Unspecified

The shoulder pain family identifies the side specifically: right is coded M25.511, left is coded M25.512, and if the side is not specified, it is coded M25.519. Shoulder pain that occurs on both sides is coded using the right and left codes, both if the symptoms are reported.

Being unspecified does not mean the pain is on both sides. Likewise, an unknown cause of the pain does not mean the side is unspecified. If the provider knows the pain is on the left, and is documenting their findings to determine a cause, M25.512 is used to describe the laterality.

If the patient’s provider has not indicated the side, laterality is established if a consensus exists among other providers documenting the condition. Discrepancies require clarification. If the documentation does not clarify the side, use unspecified laterality.

Discrepancies in the assessment should be reported and the documentation reviewed, rather than choosing the side that occurs more frequently.

A patient stating their right arm is dominant, does not mean their right shoulder is painful. Likewise, just because a diagnosis is labeled “left,” does not mean a right shoulder diagnosis should be changed.

More Specific Shoulder Conditions and Nearby Pain

A code lookup becomes more useful when it shows what changes the selection. The following diagnoses require documentation of the condition itself.

The official CMS code files provide the descriptors and category instructions behind these distinctions. 

Rotator cuff injuries require separate consideration

Although “not specified as traumatic” matters in the family of codes for M75.1, it should not be assumed that all tears are classified as traumatic injuries. Follow the Index and appropriate defaults.

For a documented traumatic left rotator cuff strain, the code S46.012A is for a strain of the rotator cuff muscles and tendons, left shoulder, for the first indication. Other particulars of the injury may result in different codes.

The distinctions of A, D and S describe the circumstances of the care provided; seeing a different practitioner does not determine the extension.

The query constructively addresses an unresolved documentation issue. For example, a clarification may be necessary if the assessment indicates a degenerative tear while a different, relevant statement may indicate a traumatic rupture. Resolving the contradiction based upon the mechanism is not appropriate for a coder to do.

Other terms require specific language

M75.22 is for bicipital tendinitis. Shoulder tendinitis in general does not point to the involvement of the biceps tendon.

M25.612 is for left shoulder stiffness. Restricted movement in a joint may be caused by several conditions. Therefore, stiffness does not point to adhesive capsulitis.

R29.898, other symptoms and signs involving the musculoskeletal system, may be appropriate for documented weakness of a limb following index review. M62.81 is for generalized muscle weakness. Neither of these should be added automatically for a report of lost muscle strength.

It is important to note the distinction of an examination finding and what is reportable based upon the entire record.

Shoulder, arm and cervical pain in different locations

Upper-arm and arm pain are described in M79.602 and M79.622, respectively. M25.512 should not be replaced by these codes simply because a patient points broadly toward the shoulder region.

Cervical radiculopathy, if documented, justifies M54.12. If a cervical disc disorder or spondylosis is associated with the radiculopathy, check the relevant combination-code instructions.

Radiation of pain by itself does not confirm the presence of radiculopathy. Shoulder-blade pain requires careful localization; it may be referred pain of muscular or costal origin, or of thoracic spine.

Excludes1 and Excludes2 Notes

Always refer to the notes at the code level, its parent level and the final category level. Examining only the final code can miss instructions carried over from sub categories or higher level codes.

Excludes2 notes allow distinct conditions

Limited by the Excludes2 notes, M25.5 carries shoulder and upper-arm pain. These conditions do not fall under the joint pain category, but can coexist with joint pain.

For example, if left shoulder joint pain and left upper-arm pain are separately documented and reported, both codes are appropriate. The presence of an Excludes2 note does not mean a code must be reported in addition to the other code, and describing the same condition in two different ways does not justify reporting two separate conditions.

Shoulder calcification is covered by an Excludes2 note in M25, and this does not override the rules governing conditions that are routinely associated with a specific finding.

Excludes1 note requires a different approach

M75.1 is covered by an Excludes1 note for traumatic rotator cuff tears, and S46.01-. The same tear should not be represented as traumatic and not traumatic.

Official Excludes1 convention states that unrelated conditions should be disregarded. So if the relationship between conditions is not clear, clarification should be sought as opposed to applying an “absolute never on the same claim” rule.

This is one reason a competitor’s “cannot bill together” list should be verified. A formal exclusion note, a symptom-reporting rule, and a payer edit are separate reasons a code combination may require review.

Acute, Chronic, and Postprocedural Pain

M25.512 identifies the location of the pain but does not express if pain is acute or chronic or if it is post-procedural or part of a pain syndrome. A G89 code can only be reported when the provider has clearly documented that type of pain and the circumstances support the use of that code. Other chronic pain is described in G89.29, and Acute Pain due to Trauma is described in G89.11. Chronic Pain Syndrome is described in G89.4.

A G89 code should not be added if the patient has shoulder pain. The underlying shoulder condition should be coded if that is the focus of the encounter. Pain control should be coded according to the reason for the encounter. Expected Post Operative pain should not be coded. Post-Procedural pain should be coded based on the individual clinical circumstances.

Practices using the Pain Management Billing Services should document if the visit was for management of the underlying condition, pain, or both. This will guide the coders in applying the correct code and sequence.

Documentation That Supports Code Selection

A good record helps the next reviewer understand what was assessed and why the service was provided. It does not need a copied checklist full of findings that were never evaluated.

Capture the facts that affect the code

These are review prompts, not a universal requirement that every M25.512 record contain every item. The service and clinical circumstances determine the necessary documentation.

A concise assessment of “left shoulder pain; cause undetermined” can explain the diagnosis selection. Documentation supporting an imaging study or therapy service may require additional clinical detail.

Clarity inconsistencies without endorsing a particular diagnosis

Edit requests should identify inaccuracies and ask the provider to resolve them. For example:

“The assessment says right shoulder and the procedure note says left. Please clarify the correct side and amend the record as appropriate.”

That request is for accuracy. It is not an edit request to resolve the need for a specific diagnosis to warrant payment.

Do not simply cut and paste a diagnosis from a referral to an assessment. Keep the differences in the level of confirmation and reasoning for the referral visible to the coder.

Apply the diagnostic test exception correctly

When a diagnostic test is completed on an outpatient basis and a final interpreting physician establishes a diagnostic judgment, that final report serves as the basis for the interpretation of the diagnostic service under the criteria of the applicable exception.

Just because a test has been interpreted to establish a diagnosis in no way gives the coder the latitude to diagnose a tear from an image, or to interpret an isolated study sign, or to use the exception for a diagnostic test for every office visit.

Code the service rendered based on the document source, the place of service and the kind of claim, i.e. the office claim vs. diagnostic service claim. This helps resolve apparent discrepancies in the office based service and the diagnostic service.

Billing Checks Before Claim Submission

A billable diagnosis code captures the required details for reporting, but does not grant coverage for every service linked to a diagnosis of shoulder pain.

Evaluate the clinical information and payer’s coverage, authorization, and claim requirements. If a service is authorized, ensure the service and site performed is aligned with the authorized service.

There is no specific CPT code for left shoulder pain. The ICD-10-CM code is specific to the diagnosis and does not describe the service or procedure. Therefore, services such as an examination, an imaging study, an injection, and therapy each require assignment of a CPT code.

The appropriate order for claim review is to:

• Match the assessment with the diagnosis.
• Verify the code was reported for the problem diagnosed.
• Ensure the diagnosis code is complete. Avoid a parent code such as M25.51 when a more specific code is reportable.
• Consider laterality of the diagnosis. Review the modifiers, if any, with the documentation and diagnosis.
• Determine if the service is appropriately related to the diagnosed condition.
• Clarify the service, if required, with a service modification.

Review coverage requirements. Ensure the proper authorization and medical necessity criteria are documented.

Reconcile any discrepancies. Correct supported errors. If any unsupported errors are identified, obtain clarification prior to submission.

Review the actual reason a claim was denied. An incomplete code will have a different response than a denial involving authorization or coverage. Change the diagnosis only if there is supporting record documentation.

Prior review mistakes that can be caught during routine editing

• Transposing M25.512 into M25.521 to show right elbow pain.
• Using M75.01 to code left frozen shoulder (Right frozen shoulder is coded M75.00).
• Coding every rotator cuff tear as S46.012A.
• Concluding a positive shoulder test is a confirmed diagnosis.
• Automatically adding a code for pain to every diagnosed shoulder disorder.
• Using more detailed diagnostic codes to support a more comprehensive diagnosis and guarantee a higher payment.

Maintain a correction log that identifies the error, its source, the record and the action taken. This not only identifies recurring problems, but allows problems to be resolved using multiple methods such as training, templates and claim reviews.

Clinical Context and Urgent Warning Signs

The American Academy of Orthopaedic Surgeons designates rotator cuff tendinitis, bursitis, and impingement as causes of shoulder pain. Other causes can be from conditions and injuries not related to the shoulder. Arthritis and “frozen” shoulder can also lead to shoulder pain.

Pain and stiffness in the shoulder can be from multiple conditions and can overlap. Shoulder pain and tenderness can be from bursitis. Decreased range of motion can be from tendinitis.

Call 911 for shoulder pain if symptoms of a heart attack or other cardiac event are occurring such as pain radiating to the shoulder from the chest or if there are accompanying shortness of breath, dizziness, sweating, or other symptoms of a cardiac event. Seek immediate medical attention if there is pain in the shoulder and signs of swelling, redness, and fever.

Call 911 for shoulder pain if there is swelling and redness. The presence of these symptoms can indicate a serious condition and warrant an immediate evaluation.

While these symptoms indicate a need for an immediate evaluation, they do not allow for a code to be assigned for a cardiac condition on an outpatient claim.

Three Practical Coding Scenarios

The following cases are for teaching and do not illustrate patient outcomes or voucher results.

Case 1: Documented case of left shoulder pain with suspected impingement syndrome

Record: The clinician documents left shoulder pain, and the patient reports discomfort with overhead movements. An impingement syndrome is suspected and more testing is ordered.

Selection: Code M25.512 represents the symptom documented. Established case of impingement syndrome is not documented.

Review point: A positive test or physical examination findings may support a clinician’s reasoning for a diagnosis but may not establish the diagnosis for the purpose of code assignment. Code assignment should reflect the level of confidence the clinician has in the diagnosis.

Case 2: Established case of left adhesive capsulitis

Record: The provider documents the case of left adhesive capsulitis. The restriction in range of motion in the left shoulder is attributed to adhesive capsulitis.

Selection: Code M75.02 is assigned to represent the case of adhesive capsulitis.

Review point: For every established case of a condition and its signs and symptoms, codes should be assigned only once. Separate, reportable conditions should be assigned their own codes. Codes M25.512 and M25.612 should not be assigned for adhesive capsulitis.

Useful coding change occurs with establishment of the diagnosis. It is not dependent upon the symptom becoming more severe or upon practice wishing to achieve a different reimbursement outcome.

Case 3: Clear laterality

Record: The clinician documents the case of right shoulder pain, and the patient reports left shoulder pain. Both should be documented as impingement syndrome. Both right and left symptoms affect the plan of care.

Selection: M25.511 and M25.512 are assigned to represent the symptoms of the right and left shoulder respectively.

Review point: Discarding information provided by the case record with the use of M25.519 is not allowed. If a procedure is performed on the right shoulder only, the diagnosis relationship and modifier should reflect the case of the right shoulder.

Frequently Asked Questions

What is the ICD-10 code for left shoulder pain?

The left shoulder pain ICD 10 code is M25.512, “Pain in left shoulder.” It identifies the symptom and the affected side. Use it when the documentation supports that symptom; a confirmed underlying condition may call for a different code or a different reporting decision.

Is M25.512 a billable diagnosis code?

Yes. M25.512 is a complete, billable ICD-10-CM diagnosis code. Billable status means the code is sufficiently detailed for reporting; it does not guarantee payment. Coverage still depends on the service, documentation, medical necessity, authorization requirements, and other applicable payer rules for the claim.

What is the code for bilateral shoulder pain?

Report M25.511 for right shoulder pain and M25.512 for left shoulder pain when both are documented and reportable. The shoulder-pain family has no bilateral code. M25.519 means the side is unspecified, so it should not replace the two codes when both sides are known.

What is the difference between M25.512 and M25.612?

M25.512 describes pain in the left shoulder. M25.612 describes stiffness of the left shoulder, not elsewhere classified. They represent different findings. Report either or both only when documentation and coding rules support doing so; do not automatically add both for symptoms integral to a confirmed condition.

Can M25.512 be used for chronic left shoulder pain?

Yes, M25.512 can describe the site of documented chronic left shoulder pain. An additional G89 code may be appropriate when it adds supported information and the encounter meets the relevant rules. G89.29 describes other chronic pain; G89.4 requires a specific diagnosis of chronic pain syndrome.

Can M25.512 be reported with a rotator cuff tear?

Pain routinely associated with a confirmed rotator cuff tear generally is not separately reported with M25.512. Review the complete record, encounter purpose, and coding instructions before combining codes. Separate reportable conditions or a qualifying pain-management encounter require their own assessment rather than an automatic pairing.

What is the CPT code for left shoulder pain?

There is no CPT code that simply means left shoulder pain. M25.512 is an ICD-10-CM diagnosis code. The CPT code depends on the service performed, such as an examination, imaging study, injection, or therapy. Select the procedure code from the documented service and applicable instructions.

Is M25.521 the code for left shoulder pain?

No. M25.521 describes pain in the right elbow. M25.512 describes pain in the left shoulder. The similar digits make this an easy transcription error. Check the full description against the assessment, especially when codes are entered manually or selected from a saved list.

Putting the Code Into Practice

Start coding accurate left shoulder pain ICD 10 codes at M25.512 and review the assessment. Determine the side, and differentiate a symptom from an established condition. Add any instructions, affect code sequencing, or add additional codes affected by the instructions.

Do your coding and billing team repeatedly need to correct shoulder claims? Then ask them to conduct a focused review of a small sample of assessments, orders, procedure notes, and claim edits.

Coding related workflow issues can be resolved by conducting focused reviews.

Authoritative external links

1. CDC/NCHS ICD-10-CM files: Code verification and applicable releases.
2. CMS ICD-10 resources: Official coding guidelines and code tables.
3. AAOS OrthoInfo: Clinical context for rotator cuff tendinitis, bursitis, and impingement.