Introduction
According to the National Institutes of Health (NIH), shoulder pain is the third most common musculoskeletal presentation in primary care, following back and knee pain. Each year, approximately 1% of adults consult for new-onset shoulder pain, with rotator cuff disorders accounting for nearly 85% of cases. Other common causes include glenohumeral joint dysfunction, acromioclavicular (ACJ) pathology, and referred pain from the cervical spine. While most cases resolve with conservative management, chronicity is not uncommon, an estimated 14% of patients continue to seek care three years after initial presentation.
The ICD-10 code for right shoulder pain (M25.511) is a symptom-level code used when right-sided shoulder pain is present but the underlying pathology has not yet been confirmed. It allows providers to document symptoms during the early phase of evaluation and supports medical necessity for imaging, therapy, or specialist referral. Accurate application of M25.511 ensures coding compliance, appropriate claim submission, and alignment with clinical documentation.
What You’ll Learn
In this guide, you’ll learn how to:
- Assign ICD-10 Code for Right Shoulder Pain (M25.511) accurately for right shoulder pain
- Differentiate between symptom-level coding and specific shoulder diagnoses
- Link M25.511 to clinical services like diagnostic imaging and referrals
- Understand documentation standards for clean claims
- Prevent common coding errors that trigger denials
What Is Right Shoulder Pain?
Right shoulder pain refers to discomfort, stiffness, or limited range of motion involving the glenohumeral joint, acromioclavicular joint, or surrounding soft tissues on the right side. It may be caused by:
- Overuse injuries (e.g., rotator cuff strain, impingement)
- Degenerative conditions (e.g., osteoarthritis, tendinopathy)
- Inflammatory disorders (e.g., bursitis, adhesive capsulitis)
- Acute trauma (e.g., dislocation or fracture)
- Referred pain from cervical spine or cardiac origin
In early presentations where no definitive diagnosis has been confirmed, documentation must reflect the symptom of right shoulder pain, not a specific condition making M25.511 the appropriate ICD-10 code.
What Is the ICD-10 Code for Right Shoulder Pain?
The official ICD-10 code for right shoulder pain is:
M25.511 – Pain in right shoulder
This code is part of the ICD-10-CM system, which classifies diagnoses and symptoms in U.S. healthcare. It is located in Chapter 13: Diseases of the Musculoskeletal System and Connective Tissue, which includes all disorders affecting joints, bones, muscles, and connective structures.
Use ICD-10 Code M25.511 When:
- Pain is clearly localized to the right shoulder
- The underlying cause (e.g., tear, arthritis, dislocation) is not yet confirmed
- The visit is focused on evaluating or managing the pain symptom itself
M25.511 is a non-specific symptom code, most appropriate during initial assessments when a definitive diagnosis is pending.
Once a specific diagnosis is established (e.g., rotator cuff tear, M75.101), you should replace M25.511 with the corresponding diagnosis code.
When to Use M25.511 for Right Shoulder Pain
Apply M25.511 when:
- Right shoulder pain is the primary complaint and no underlying pathology is diagnosed
- The patient is in the early evaluation phase, and imaging/labs are in progress
- The provider needs to justify referrals or imaging studies
- Symptoms are functional (affecting sleep, range of motion, or daily activities)
Do not use M25.511 if:
- The patient has a known condition like rotator cuff tear (M75.101), adhesive capsulitis (M75.01), or osteoarthritis (M19.011)
- The pain is generalized without laterality or documentation of location
Right Shoulder Pain vs. Specific Diagnoses: Code Selection Table
| Criteria | Symptom Code – M25.511 | Specific Diagnosis Code (e.g., M75.101) |
|---|---|---|
| Clinical Certainty | Unconfirmed | Confirmed diagnosis via imaging or exam |
| Use Case | Initial or undiagnosed pain | Established condition |
| Code Type | Symptom-level | Etiology-based |
| Medical Necessity Support | Imaging, therapy, referral | Treatment plan (e.g., surgery, injections) |
| Update Required? | Yes, once diagnosis is known | No, used for ongoing management |
Linking M25.511 to Diagnostic Testing and Referrals
The use of ICD-10 Code for Right Shoulder Pain (M25.511) provides clinical and payer justification for ordering:
- X-ray or MRI of the right shoulder
- Referral to orthopedic or physical therapy
- Trial of anti-inflammatory medications or corticosteroid injection
- Assessment for referred pain from the neck or thoracic region
Example Clinical Scenario:
HPI: Patient reports right shoulder pain for 3 weeks, worsened by overhead movement and lying on the affected side. No trauma reported.
PE: Tenderness over the lateral deltoid; limited abduction due to pain.
Plan: Order shoulder MRI and initiate conservative treatment.
ICD-10 Code: M25.511 – Pain in right shoulder
Pediatric and Geriatric Use of M25.511
While right shoulder pain is common in adults and athletes, it also presents in:
- Adolescents with overuse injuries or growth plate inflammation
- Elderly patients with rotator cuff degeneration or arthritis
Use M25.511 only if no underlying condition is confirmed. Once the clinical picture becomes clearer, update to a more specific ICD-10 code (e.g., M75.51 – Bursitis of right shoulder).
Can M25.511 Be a Primary Diagnosis?
✅ Yes, use M25.511 as the primary diagnosis when:
- The patient presents with right shoulder pain as the chief complaint
- No confirmed diagnosis exists at the time of the encounter
- The visit’s focus is on initial workup or symptom management
❌ Do not use it as primary if:
- The patient is being managed for an already diagnosed condition
- Pain is being documented solely as a secondary symptom
How Pro-MBS Ensures Accurate ICD-10 Coding for Shoulder Pain
The Pro-MBS coding team offers specialized expertise in musculoskeletal ICD-10-CM coding and documentation integrity, with a focus on pain-related presentations such as right shoulder pain. Our process-driven approach ensures:
- Precise assignment of ICD-10 code M25.511 during the initial evaluation phase, based on clinical presentation and laterality
- Cohesive alignment of clinical documentation with associated CPT codes for diagnostic imaging, physical therapy, or specialist referral
- Audit-compliant documentation protocols that adhere to payer-specific policy requirements and medical necessity criteria
- Structured guidance for upcoding to definitive diagnoses (e.g., M75.101, M19.011) once the underlying etiology is confirmed via imaging or physical examination
