M25.511 - Pain in right shoulder

Clinical Definition

A medical diagnosis of chest pain that is not specifically attributed to angina or other specified heart conditions. This represents chest discomfort reported by the patient without clear cardiac etiology.

Documentation Requirements

• Location must be documented:

  • Precordial

  • Left-sided

  • Right-sided

  • Anterior chest wall

  • Other specific chest area

• Temporality:

  • Onset (acute vs. chronic)

  • Duration

  • Frequency of episodes

• Character of pain:

  • Sharp

  • Dull

  • Pressure

  • Burning

• Associated symptoms

• What makes it better/worse

• Rule-out documentation for cardiac causes

Common Synonyms

• Chest discomfort

• Chest tightness

• Chest pressure

• Chest burning

• Thoracic pain

• Non-cardiac chest pain

Coding Conflicts

Excludes1:

• Angina pectoris (I20.-)

• Precordial pain (R07.2)

• Pain in breast (N64.4)

Excludes2:

• Chest pain with documented coronary artery disease

• Epigastric pain (R10.13)

Scribing.io Automation

The AI scribe automatically:

• Identifies chest pain descriptions in patient narratives

• Flags when cardiac causes are mentioned or ruled out

• Tags location-specific mentions of chest discomfort

• Captures temporal patterns of pain

• Notes associated symptoms for comprehensive documentation

• Highlights missing elements needed for complete chest pain documentation