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

ICD-10 Coding for Cervical Muscle Strain

S16.1XXA

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

Also Known as:
Neck Muscle Strain
Cervical Strain
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Key Information: ICD-10 Coding for Cervical Muscle Strain

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

Use ICD-10 code S16.1XXA for strain of muscle, fascia, and tendon at neck level, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Strain of muscle, fascia, and tendon at neck level, initial encounter

Billable Code
S16.1XXA
Billable

Diagnostic Criteria

clinical:
  • • Presence of muscle tenderness and reduced ROM without ligament damage
coding:
  • • Use S16.1XXA for initial encounters
documentation:
  • • Document specific muscles and ROM limitations

Applicable To

  • • Acute cervical muscle strain

Important Notes

  • • Ensure to document specific muscles involved and use appropriate 7th character for encounter type.
Ancillary Codes

Additional codes that may be used with this diagnosis

M53.82

Other specified dorsopathies, cervical region

Use for chronic or recurrent cervical strain with degenerative changes.

Frequently Asked Questions

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

The ICD-10 code for cervical muscle strain is S16.1XXA, used for initial encounters of acute neck muscle strain.

How do you document cervical muscle strain?

Document specific muscles involved, range of motion limitations, and exclude ligamentous injury to accurately code cervical muscle strain.

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