M25.511: Pain in right shoulder

The ICD-10-CM code for right shoulder pain when pain in the right shoulder is the primary presenting complaint and no definitive underlying diagnosis has been established at the time of coding.

Billable

FY2027

TABLE OF CONTENTS

Example H2

Medical scribe app interface showing a recording waveform, a list of patient notes, and a SOAP note for John Doe.

Stop looking up codes.

Scribe auto-generates them for you.

Try Commure Scribe →

At a glance

Code Family

M25.51: Pain in shoulder, the parent subcategory, which is not itself billable.

DRG Grouping

MS-DRG 555 or 556, signs and symptoms of musculoskeletal system and connective tissue with or without MCC, in MDC 08 under the FY2027 MS-DRG v44 grouper. M25.511 fits outpatient encounters where the workup is incomplete. In the inpatient setting it is assigned only as a residual when no related diagnosis, confirmed or uncertain, is documented at discharge.

HCC Mapping (v28)

None: M25.511 does not map to any HCC in CMS-HCC v28, and shoulder pain as a symptom code carries no risk adjustment weight.

Condition

Shoulder pain

Family Specificity

Laterality is required at the sixth character: M25.511 is the right shoulder, M25.512 the left, M25.519 the unspecified shoulder.

Which shoulder pain code do I assign?

Within the M25.51 subcategory the codes are separated only by side. The choice turns entirely on the laterality the provider documented. The prior question is whether a definitive shoulder diagnosis has been established at the encounter, because if one has, that diagnosis is coded in place of the pain code.

When documentation says…

Code

Right shoulder pain, no definitive diagnosis established

M25.511

Use when pain in the right shoulder is the primary presenting complaint and imaging, examination or other workup has not identified a definitive musculoskeletal condition. The note must name the right side explicitly.

Left shoulder pain, no definitive diagnosis established

M25.512

The mirror code for the left shoulder on the same terms. When both shoulders are painful, assign separate codes for each side, M25.511 and M25.512, rather than a single bilateral code.

Shoulder pain, side not documented

M25.519

The residual code for shoulder pain when laterality is absent from the record. Check the orthopedic or primary care note for laterality. Query the provider for the side rather than defaulting to this code.

Tabular notes

EXCLUDES2: M25 CATEGORY LEVEL

Abnormality of gait and mobility (R26.-), acquired deformities of limb (M20-M21), calcification of bursa (M71.4-), calcification of shoulder (joint) (M75.3), calcification of tendon (M65.2-), temporomandibular joint disorder (M26.6-) and difficulty in walking (R26.2). These notes sit on category M25 and reach M25.511 through it. An Excludes2 note means the excluded condition is not part of M25. Both codes may be reported together when the patient has both conditions.

EXCLUDES2: M25.5 SUBCATEGORY LEVEL

Pain in hand (M79.64-), pain in fingers (M79.64-), pain in foot (M79.67-), pain in toes (M79.67-) and pain in limb (subcategory M79.6). These notes sit on subcategory M25.5 and reach M25.511 through it. Pain documented in one of these sites is coded to the M79.6- codes rather than to the M25.5 joint pain codes.

SYMPTOM CODE CONVENTION

M25.511 is a symptom code for pain localized to the right shoulder joint without an established underlying structural diagnosis. Guideline I.B.5 states that signs and symptoms associated routinely with a disease process should not be assigned as additional codes. M25.511 should not be reported once a definitive shoulder diagnosis such as rotator cuff tear or glenohumeral osteoarthritis is established.

SEQUENCING WHEN A DIAGNOSIS EMERGES

When shoulder pain is a presenting symptom that leads to a confirmed diagnosis during the same encounter, code the confirmed diagnosis rather than M25.511. Code the symptom only when it is the final coded reason for the visit.

BILATERAL SHOULDER PAIN

For bilateral shoulder pain, assign separate codes for each side, M25.511 for the right and M25.512 for the left.

NO USE ADDITIONAL OR CODE FIRST

M25.511 does not carry a mandatory tabular-level Use Additional or Code First instruction. Chapter 13 carries a general note to use an external cause code following the musculoskeletal code, if applicable, to identify the cause.

FY2027 CHANGES

M25.511 is unchanged in the FY2027 update, effective 1 October 2026. The FY2027 codes addenda add, delete or revise no code in category M25. The FY2027 tabular addenda change no note in category M25.

Operational & financial impact

Why specificity matters beyond the chart: risk adjustment, DRG assignment and denial exposure all follow from which code is selected.

CMS-HCC v28 (PY2024+)

No HCC mapping applies. M25.511 does not map to any HCC in CMS-HCC v28, and shoulder pain as a symptom code carries no risk adjustment weight.

Where the clinical and claims weight sits instead

The underlying structural diagnoses that shoulder pain can resolve into, such as a rotator cuff tear or glenohumeral osteoarthritis, are coded to their own categories. Establishing and documenting the definitive diagnosis is what moves the encounter off a symptom code.

Outpatient and inpatient use

M25.511 fits outpatient encounters where the workup is incomplete. In the inpatient setting, M25.511 is the principal diagnosis only when no related diagnosis, confirmed or uncertain, is documented at discharge.

Medicare and commercial payers

No National Coverage Determination governs shoulder pain coding, and M25.511 does not carry HCC v28 risk adjustment weight. Section IV.D of the guidelines accepts symptom codes for outpatient visits when a diagnosis has not been established.

Documentation checklist to support M25.511

Chart elements that support code selection and reduce specificity-driven denials.

Right shoulder pain documented by the provider as the diagnosis or the primary presenting complaint.

Explicit laterality: the note names the right shoulder rather than leaving the side unspecified.

No definitive structural diagnosis established at the encounter, such as rotator cuff tear, tendinitis or osteoarthritis.

Confirmation that the pain is not integral to a diagnosis already coded at the same encounter, since a symptom integral to a confirmed diagnosis is not reported separately.

Separate documentation of each side when both shoulders are painful. M25.511 and M25.512 can then both be assigned.

FAQ

Should I use M25.511 or the specific shoulder diagnosis code?

Use the specific diagnosis code whenever one is established. M25.511 is appropriate only when pain is the primary complaint and no definitive diagnosis has been made at the time of coding.

My patient has right and left shoulder pain. Do I need two codes?

Yes. Assign M25.511 for the right shoulder and M25.512 for the left. Do not use M25.519, pain in unspecified shoulder, when laterality is known.

Can M25.511 be coded alongside the definitive diagnosis it turned out to be?

No. M25.511 is not coded alongside a diagnosis to which the pain is integral. Signs and symptoms that are integral to a confirmed diagnosis are not coded separately. When shoulder pain is the presenting symptom that leads to a confirmed diagnosis during the same encounter, only the confirmed diagnosis is coded.

Does M25.511 carry any risk adjustment weight?

No. M25.511 does not map to any HCC in CMS-HCC v28, and shoulder pain as a symptom code carries no risk adjustment weight.

What if the shoulder pain is coming from the neck?

Shoulder pain attributable to cervical radiculopathy is coded to M54.12 rather than M25.511. M25.511 is reserved for pain localized to the right shoulder joint itself without an established underlying structural diagnosis.

Is M25.511 appropriate for an inpatient stay?

M25.511 fits an inpatient stay only when no related diagnosis, confirmed or uncertain, explains the pain at discharge. Section II.H directs inpatient coders to code a diagnosis documented at discharge as probable or suspected as if it existed.

Related codes

Codes in the same family as M25.511. Only codes with a published page render as links.

Sibling codes in the M25.51 family

M25.511: Pain in right shoulder.
M25.512: Pain in left shoulder.
M25.519: Pain in unspecified shoulder.
M25.51-: Pain in shoulder, the parent subcategory, which is not billable.

Additional codes to consider

Codes outside the M25.51 family considered alongside M25.511.

Consider instead

M75.111: Incomplete rotator cuff tear or rupture of right shoulder, not specified as traumatic. Assign instead when an incomplete rotator cuff tear is established.
M19.011: Primary osteoarthritis, right shoulder. Assign instead when shoulder osteoarthritis is established.
M75.01: Adhesive capsulitis of right shoulder. Assign instead when frozen shoulder is documented on the right.
M75.00: Adhesive capsulitis of unspecified shoulder, frozen shoulder. Assign when adhesive capsulitis is documented without a side.
M75.41: Impingement syndrome of right shoulder. Assign instead when impingement is the documented diagnosis.
S40.011A: Contusion of right shoulder, initial encounter. Assign instead when a contusion of the right shoulder is documented.
M54.12: Radiculopathy, cervical region. Assign instead when the shoulder pain is attributable to cervical radiculopathy.

Sources

All claims on this page derive from government and professional-standards sources.

National Center for Health Statistics. (2026). International classification of diseases, tenth revision, clinical modification (ICD-10-CM) FY2027 files. https://www.cdc.gov/nchs/icd/icd-10-cm/files.html
Centers for Medicare & Medicaid Services and National Center for Health Statistics. (2026). ICD-10-CM official guidelines for coding and reporting FY2027. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/2027/ICD-10-CM-October-1-2026-FY27-Guidelines.pdf
Centers for Medicare & Medicaid Services. (2025). 2026 model software/ICD-10 mappings. https://www.cms.gov/medicare/payment/medicare-advantage-rates-statistics/risk-adjustment/2026-model-software-icd-10-mappings
Centers for Medicare & Medicaid Services. (2026). MS-DRG classifications and software, version 44. https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/ms-drg-classifications-and-software