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Home/Diagnosis/ICD-10 Coding for Back Muscle Strain

ICD-10 Coding for Back Muscle Strain

S39.012A
S29.012A

Complete ICD-10-CM coding and documentation guide for icd-10 coding for back muscle strain includes clinical validation requirements, medical necessity guidelines, and coding policies.

Also Known as:
Lumbar Strain
Thoracic Strain
Back Sprain
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Key Information: ICD-10 Coding for Back Muscle Strain

Essential facts and insights about ICD-10 Coding for Back Muscle Strain

Use ICD-10 code S39.012A for strain of muscle, fascia and tendon of lower back, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Strain of muscle, fascia and tendon of lower back, initial encounter

Billable Code
S39.012A
Billable

Diagnostic Criteria

clinical:
  • • Presence of acute pain and tenderness in lower back muscles
coding:
  • • Documented mechanism of injury leading to muscle strain

Applicable To

  • • Acute lower back muscle strain

Important Notes

  • • Ensure documentation specifies 'strain' and not just 'pain' to use this code.

Strain of muscle, fascia and tendon of upper back, initial encounter

Billable Code
S29.012A
Billable

Applicable To

  • • Acute upper back muscle strain

Important Notes

  • • Ensure documentation specifies 'strain' and not just 'pain' to use this code.
Ancillary Codes

Additional codes that may be used with this diagnosis

M54.5

Low back pain

Use as an ancillary code if pain persists beyond the acute phase of the strain.

Frequently Asked Questions

What is the ICD-10 code for back muscle strain?

The ICD-10 code for a strain of the lower back muscle is S39.012A, while S29.012A is used for upper back muscle strain.

How do you code back pain associated with a strain?

Use S39.012A or S29.012A for the strain and M54.5 as an ancillary code if pain persists.

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