Complete ICD-10-CM coding and documentation guide for icd-10 coding for cervical spine strain includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Cervical Spine 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.
Additional codes that may be used with this diagnosis
Cervicalgia
Use to document associated neck pain.
The ICD-10 code for cervical spine strain is S16.1XXA for initial encounters, S16.1XXD for subsequent encounters, and S16.1XXS for sequelae.
Document the mechanism of injury, specific muscles involved, and clinical findings such as tenderness and range of motion limitations.