Left Shoulder Pain ICD 10 Code: What Providers Need to Know
October 6, 2026
The ICD-10-CM code for pain in the left shoulder is M25.512. It is generally appropriate when the provider documents left shoulder pain but has not established a more specific underlying condition.
If the physician confirms a condition such as bursitis, adhesive capsulitis, impingement syndrome, osteoarthritis, or a rotator cuff disorder, a more specific diagnosis code may better describe the patient’s condition.
This guide explains when M25.512 is appropriate, how it differs from related shoulder diagnosis codes, and what documentation can support services such as imaging, injections, and physical therapy.
What Is the ICD-10 Code for Left Shoulder Pain?
The ICD-10-CM code generally used for left shoulder pain is:
| ICD-10-CM Code | Description |
|---|---|
| M25.512 | Pain in left shoulder |
| M25.511 | Pain in right shoulder |
| M25.519 | Pain in unspecified shoulder |
The code belongs to the M25 category, which covers other joint disorders, including joint pain.
For a patient whose documented complaint and clinical assessment are simply left shoulder pain. Where the cause has not yet been confirmed M25.512 could be the appropriate diagnosis code, for left shoulder pain.
The word left matters.
When the medical record clearly shows the shoulder using a vague shoulder code can lose useful clinical detail in the medical record and may raise extra questions, about the left shoulder claim.
When Should Providers Use M25.512?
M25.512 is most useful when shoulder pain itself is the condition being evaluated and a more specific cause has not yet been established.
For example, consider a patient who develops gradually worsening left shoulder pain over several weeks. The provider documents:
- Left shoulder pain with overhead movement
- No known acute injury
- Mild loss of range of motion
- Tenderness during examination
- Imaging ordered to determine the underlying cause
At this point the provider may not know if the problem is bursitis, rotator cuff pathology, arthritis or another disorder.
In that situation coding the documented symptom, with M25.512 may accurately reflect what is known on that date of service.
Later if diagnostic testing and clinical evaluation confirm a condition then a more precise diagnosis can be used for future visits.
M25.512 Should Not Replace a Confirmed Diagnosis
One common coding problem occurs when a practice continues using a general pain diagnosis even after the provider has identified the underlying disorder.
Left shoulder pain can occur with numerous conditions, and several have their own ICD-10-CM codes.
Common examples include:
| Condition | Possible ICD-10-CM Code |
|---|---|
| Pain in left shoulder | M25.512 |
| Stiffness of left shoulder, NEC | M25.612 |
| Adhesive capsulitis of left shoulder | M75.02 |
| Bicipital tendinitis, left shoulder | M75.22 |
| Calcific tendinitis, left shoulder | M75.32 |
| Impingement syndrome, left shoulder | M75.42 |
| Bursitis of left shoulder | M75.52 |
| Primary osteoarthritis, left shoulder | M19.012 |
| Secondary osteoarthritis, left shoulder | M19.212 |
| Complete nontraumatic rotator cuff tear/rupture, left shoulder | M75.122 |
CMS coding references includes codes for conditions like left shoulder impingement (M75.42) left shoulder bursitis (M75.52) bicipital tendinitis (M75.22) and a complete nontraumatic tear of the left rotator cuff (M75.122).
The main thing to remember is to code based on what the medical documentation actually supports.
Don’t pick a diagnosis just because it seems possible or fits the picture. Once the provider has clearly confirmed a diagnosis ask yourself if a general pain code still makes sense for this visit. The diagnosis code must match the condition the provider has documented and the reason, for the patient’s visit.
Left Shoulder Pain vs. Left Shoulder Stiffness
Pain and stiffness may occur together, but ICD-10-CM treats them as separate findings.
M25.512 represents pain in the left shoulder.
M25.612 represents stiffness of the left shoulder, not elsewhere classified. CMS’s ICD-10-CM tabular material identifies M25.612 specifically as stiffness of the left shoulder.
A provider should therefore document what is actually present.
For example:
Patient says left shoulder pain is 6 out of 10 and shows active shoulder flexion and less active shoulder abduction.
This note gives a clearer picture of the patient’s condition than just writing “shoulder problem.”
Whether both findings should be coded depends on the circumstances the coding guidelines, medical necessity and whether each condition is relevant, to the services performed.
Adhesive Capsulitis and Left Shoulder Pain
A patient who is in a lot of pain and is slowly losing shoulder movement may ultimately receive a diagnosis of capsulitis. Adhesive capsulitis is the term, for frozen shoulder and it can make the shoulder feel stuck and hard to move.
The ICD-10-CM code for adhesive capsulitis of the left shoulder is M75.02. CMS’s tabular classification distinguishes:
- M75.00 – unspecified shoulder
- M75.01 – right shoulder
- M75.02 – left shoulder
If adhesive capsulitis has been clinically established and is the condition being treated, M75.02 generally provides more diagnostic information than simply reporting M25.512.
Rotator Cuff Conditions Require Careful Coding
Not every painful shoulder is a rotator cuff tear. The rotator cuff tear is not the cause of shoulder pain. The rotator cuff tear can be mistaken for shoulder problems.
Providers should distinguish between suspected pain confirmed rotator cuff conditions and traumatic injuries. The rotator cuff conditions that are not caused by trauma must be identified separately from injuries. The rotator cuff conditions that are traumatic belong to injury‑code categories.
For example M75.122 describes a rotator cuff tear or rupture of the left shoulder that is not specified as traumatic. CMS references also distinguish rotator cuff conditions, from traumatic tears, which belong to injury‑code categories. The rotator cuff distinction matters because traumatic injury coding may require elements, including the correct injury code and encounter character.
Documentation should clarify, when known:
- Whether trauma occurred
- How the injury happened
- Left versus right shoulder
- Tendon or structure affected
- Complete versus incomplete tear, when established
- Acute versus chronic presentation
- Whether imaging confirmed the diagnosis
- Whether the encounter is for active treatment, routine healing, or a residual problem when relevant to injury coding
Using M25.512 for every rotator cuff-related encounter can understate the clinical condition when a definitive diagnosis is already documented.
Impingement Syndrome
Another common source of shoulder pain is impingement syndrome.
For the left shoulder, the relevant code is:
M75.42 – Impingement syndrome of left shoulder
CMS orthopedic coding material emphasizes M75.42, for left‑sided shoulder impingement. When examination, imaging and clinical documentation confirm an established diagnosis using M75.42 can give a clearer picture of the patient’s condition than using only symptom coding.
Left Shoulder Bursitis
Shoulder bursitis can cause pain with movement, tenderness, and difficulty performing overhead activities.
The ICD-10-CM code for bursitis of the left shoulder is:
M75.52 – Bursitis of left shoulder
Again, providers should avoid assuming bursitis merely because a patient has shoulder pain. The diagnosis needs to be supported by the clinical documentation.
Left Shoulder Osteoarthritis
When pain comes from known osteoarthritis using an arthritis- code can be the right choice.
For example:
M19.012 – Primary osteoarthritis, left shoulder
The CMS references point to this code for primary osteoarthritis, in the left shoulder.
This difference matters. Pain is a symptom. Osteoarthritis is a condition. It shows what is really causing the pain. So when coding it’s better to use the code that identifies the disease, not the symptom.
Documentation may include findings such as:
- Chronic shoulder pain
- Reduced range of motion
- Crepitus
- Functional limitations
- Relevant imaging findings
- Previous treatment response
Common CPT Codes Associated With Left Shoulder Pain
There is no single CPT code for treating shoulder pain.
CPT coding depends on what the provider actually performs.
Common services may include:
| Service | Common CPT Code |
|---|---|
| Office/outpatient E/M, new patient | 99202–99205 |
| Office/outpatient E/M, established patient | 99211–99215 |
| Complete shoulder X-ray | 73030 |
| MRI of upper-extremity joint without contrast | 73221 |
| Major joint/bursa injection without ultrasound guidance | 20610 |
| Major joint/bursa injection with ultrasound guidance | 20611 |
| Physical therapy evaluation | 97161–97163 |
| Therapeutic exercise | 97110 |
| Neuromuscular re-education | 97112 |
| Manual therapy | 97140 |
| Therapeutic activities | 97530 |
These procedure codes should not be selected simply because M25.512 appears on the claim. The medical record must establish why the service was necessary.
For rehabilitation services, CMS specifically states that documentation should connect each therapeutic intervention with an expected therapeutic goal. CMS also describes CPT 97110 as therapeutic exercise intended to improve areas such as strength, endurance, range of motion, and flexibility.
Coding Shoulder Injections Correctly
Shoulder injections deserve particular attention because diagnosis coding, procedure coding, laterality, and guidance can all affect the claim.
Two frequently encountered codes are:
20610 – aspiration or injection of a major joint or bursa without ultrasound guidance.
20611 – aspiration or injection of a major joint or bursa when ultrasound guidance is included.
A shoulder is considered a major joint for these coding purposes.
Documentation should identify:
- Which shoulder was treated
- Specific joint or bursa when clinically relevant
- Medical reason for the injection
- Medication administered
- Dose or amount when required
- Technique
- Whether ultrasound guidance was used
- Relevant image documentation when required
- Patient response and complications, if any
Diagnosis selection should reflect the actual condition being treated rather than automatically defaulting to shoulder pain when bursitis, arthritis, or another disorder has already been established.
Physical Therapy and Left Shoulder Pain
Physical therapy is common for patients experiencing shoulder pain, stiffness, weakness, rotator cuff dysfunction, or postoperative functional limitations.
The diagnosis alone, however, does not demonstrate why every therapy service is medically necessary.
A stronger therapy record connects the diagnosis with a measurable functional problem.
Instead of writing:
Left shoulder pain. Exercises performed.
A more useful note might document: Patient reports left shoulder pain rated 6/10 when reaching overhead. Active flexion remains limited compared with the uninvolved side, interfering with dressing and overhead household activities. Therapeutic exercise performed to improve shoulder mobility and functional strength.
That tells a much clearer story.
CMS therapy guidance states that documentation supporting therapeutic exercise should include relevant objective measurements, the location and functional effect of pain when pain is being treated, the specific exercises performed, their functional purpose, and the skilled assistance or instruction provided.
Remember the Timed-Code Rules
Several rehabilitation CPT codes associated with shoulder treatment are billed in 15-minute units.
Examples include:
- 97110
- 97112
- 97140
- 97530
For Medicare claims, providers should pay close attention to total timed treatment minutes.
CMS provides examples showing that the number of billable units is determined from total timed treatment minutes rather than simply rounding each individual service independently. For example, CMS shows that 49 total timed minutes support three timed units, not four.
Accurate start/stop or total treatment-time documentation can therefore be important when multiple timed services occur during the same visit.
Modifiers That May Appear on Shoulder Claims
Modifiers depend on the procedure, payer, setting, and circumstances of the encounter. They should never be added automatically.
LT Modifier
LT indicates the left side of the body.
For procedures for which laterality is applicable and accepted by the payer, LT may communicate that the service involved the left shoulder.
The diagnosis code M25.512 already identifies left-sided shoulder pain, but that does not necessarily remove a payer’s requirement for procedure-level laterality.
Modifier 25
Modifier 25 may be appropriate when a significant, separately identifiable E/M service is performed on the same day as another procedure.
Its use must be supported by documentation.
The fact that an E/M visit and shoulder injection occurred on the same date does not automatically justify modifier 25.
Modifier 59 or X Modifiers
Modifier 59, or a more specific X modifier where applicable, may sometimes be necessary to identify distinct procedural circumstances when coding edits would otherwise bundle services.
These modifiers should be used only when the documentation and applicable coding rules support them.
GP Modifier
For Medicare outpatient physical therapy services, the GP modifier is commonly used to indicate that the service was delivered under a physical therapy plan of care.
KX Modifier
For Medicare therapy services, the KX modifier may become relevant after the applicable therapy threshold is reached.
CMS explains that use of KX represents an attestation that services at or above the threshold remain reasonable and medically necessary and that continued care is justified in the record.
The modifier should therefore never be treated as an automatic billing addition.
Documentation: What Should Be in the Medical Record?
Good diagnosis coding starts with good documentation.
For a left shoulder complaint, the record should make it easy to understand what the patient is experiencing, what the provider found, and why a service was performed.
Depending on the encounter, useful documentation may include:
Location
Specify the side.
Write left shoulder, rather than simply “shoulder pain.”
Onset
Document whether symptoms began:
- Suddenly
- Gradually
- After trauma
- After repetitive activity
- Following surgery
- Without an identifiable event
Pain Characteristics
Include clinically relevant information such as:
- Severity
- Duration
- Frequency
- Location
- Radiation
- Aggravating movements
- Relieving factors
- Night pain when relevant
Functional Impact
Explain what the patient cannot comfortably do.
Examples include difficulty with:
- Dressing
- Grooming
- Reaching overhead
- Lifting
- Carrying
- Sleeping on the affected side
- Performing occupational duties
- Exercising
Objective Findings
Depending on the case, this may include:
- Active range of motion
- Passive range of motion
- Strength
- Tenderness
- Swelling
- Crepitus
- Neurologic findings
- Provocative tests
- Comparison with the opposite shoulder
Clinical Assessment
Document whether the provider is treating:
- Undifferentiated shoulder pain
- Arthritis
- Bursitis
- Tendinitis
- Impingement
- Frozen shoulder
- Rotator cuff pathology
- Injury
- Another confirmed condition
That assessment drives the diagnosis-code decision.
A Simple Coding Example
Consider this initial visit:
A 52-year-old patient reports worsening left shoulder pain for three weeks without a specific injury. Pain is worse when reaching overhead. Examination shows tenderness and mild limitation of motion. No definitive condition has been established, and the provider orders an X-ray.
A reasonable diagnosis may be:
M25.512 – Pain in left shoulder
Now consider a later visit.
The patient returns after further evaluation, and the physician documents a confirmed diagnosis of left shoulder impingement syndrome.
The more specific diagnosis is:
M75.42 – Impingement syndrome of left shoulder
The second encounter illustrates why diagnosis coding should evolve as the clinical picture becomes clearer.
Common Reasons Left Shoulder Claims Run Into Problems
Claims involving shoulder care can be delayed or denied even when the diagnosis code itself is valid.
Frequent problems include:
Wrong laterality.
The medical record says left shoulder, while the claim identifies the right side or uses an unspecified diagnosis.
Diagnosis and procedure do not align.
The documentation does not clearly explain why imaging, therapy, an injection, or another service was medically necessary.
A symptom code is used despite a confirmed diagnosis.
The chart identifies a specific shoulder condition, but billing continues to rely exclusively on M25.512 without considering whether the established diagnosis should be reported.
Insufficient therapy documentation.
Treatment notes list exercises without showing the functional problem, treatment goal, skilled intervention, or patient progress.
Missing authorization.
Some payer plans require prior authorization for MRI, therapy, injections, or other services.
Incorrect modifier use.
Laterality, E/M, therapy, or distinct-service modifiers are missing or unsupported.
Timed units do not match the record.
Therapy units are reported without sufficient timed treatment minutes.
Traumatic and nontraumatic conditions are confused.
A traumatic shoulder injury may require an injury code rather than a nontraumatic musculoskeletal diagnosis.
M25.512 and Medical Necessity
A valid ICD-10-CM code does not guarantee payment.
The diagnosis must make sense in relation to the service performed.
For example, a payer reviewing an MRI, injection, or extended course of physical therapy may expect the medical record to show:
- Why the service was needed.
- What symptoms or functional deficits were present.
- What conservative treatment had already been attempted when relevant.
- How the results would affect treatment.
- Whether payer-specific coverage or authorization requirements were met.
Providers should therefore think beyond “Is M25.512 valid?” and ask:
Does my documentation explain why this patient needed this service today?
That question is often more important to claim defensibility than the diagnosis code alone.
Should M25.512 Be Used With Other Diagnosis Codes?
It depends on the encounter.
Patients can have more than one clinically relevant condition, but additional diagnoses should not be added merely to make a claim appear stronger.
For example, a patient may have documented osteoarthritis and clinically meaningful shoulder stiffness in addition to pain. Whether multiple codes should be reported depends on what was assessed, managed, and relevant during the encounter, as well as applicable coding guidelines and payer rules.
The goal is not to submit the largest possible diagnosis list.
The goal is to submit the most accurate diagnosis picture supported by the medical record.
ICD-10-CM Changes Providers Should Watch
ICD-10-CM is updated regularly, so practices should make sure they are using the code set applicable to the patient’s date of service.
As of October 2026, CMS states that the FY 2027 ICD-10-CM files apply to patient encounters from October 1, 2026 through September 30, 2027.
Even when a familiar code such as M25.512 remains unchanged, surrounding guidelines, edits, payer policies, and related codes can change.
Annual code-set review should therefore remain part of a practice’s coding workflow.
How Better Coding Protects Shoulder Claims
Shoulder claims rarely fail because someone forgot that M25.512 means left shoulder pain. Problems are more often caused by the details surrounding that code.
Was the side documented?
Was the condition traumatic?
Has a more specific diagnosis been established?
Does the imaging order match the clinical problem?
Does the therapy record show measurable functional limitations?
Does the injection documentation support the billed procedure?
Those details are what turn a diagnosis code into a defensible claim.
For practices working through recurring orthopedic claim issues, Maryland Medical Billing can help review diagnosis-to-procedure alignment, claim workflows, payer requirements, and follow-up processes while providers remain focused on clinical care.
Final Thoughts
The left shoulder pain ICD 10 code M25.512 is straightforward when the patient’s condition is truly documented as left shoulder pain without a confirmed underlying diagnosis.
The harder part is knowing when not to stop there.
If examination, imaging, or follow-up establishes arthritis, impingement, bursitis, adhesive capsulitis, tendinitis, a rotator cuff condition, or a traumatic injury, the coding should reflect the more complete clinical picture when appropriate.
Accurate laterality, specific documentation, appropriate CPT selection, supported modifiers, and a clear connection between diagnosis and medical necessity all help create cleaner claims.
For providers who want additional support managing those details across the revenue cycle, Maryland Medical Billing can assist with coding review, claim submission, denial follow-up, and payer-specific billing workflows.
Frequently Asked Questions
What is the ICD-10 code for left shoulder pain?
The ICD-10-CM code commonly used for pain in the left shoulder is M25.512.
What is the difference between M25.511 and M25.512?
M25.511 represents pain in the right shoulder, while M25.512 represents pain in the left shoulder.
What code should be used for unspecified shoulder pain?
M25.519 represents pain in an unspecified shoulder. When the side is documented, a laterality-specific code should generally be considered instead.
Can M25.512 be used for a rotator cuff tear?
M25.512 describes shoulder pain. If a rotator cuff tear has been definitively diagnosed, a more specific rotator cuff code may better represent the condition. Providers must also distinguish traumatic from nontraumatic tears.
What is the ICD-10 code for left shoulder stiffness?
M25.612 describes stiffness of the left shoulder, not elsewhere classified.
What is the code for left shoulder impingement?
M75.42 describes impingement syndrome of the left shoulder.
What is the ICD-10 code for left shoulder bursitis?
M75.52 describes bursitis of the left shoulder.
Does M25.512 require an LT modifier?
M25.512 already contains left-side specificity. However, certain procedure codes may separately require or accept an LT modifier depending on the payer and service performed. Diagnosis laterality and procedure-modifier requirements should be evaluated independently.
