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Home/Diagnosis/ICD-10 Coding for Cervical Strain

ICD-10 Coding for Cervical Strain

S16.1XXA
S16.1XXD
M54.2

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

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

Essential facts and insights about ICD-10 Coding for Cervical 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 acute neck pain and muscle tenderness
coding:
  • • Initial encounter for cervical strain

Applicable To

  • • Acute cervical strain

Important Notes

  • • Ensure documentation specifies 'strain' and the specific muscle involved.

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

Billable Code
S16.1XXD
Billable

Applicable To

  • • Follow-up care for cervical strain

Important Notes

  • • Ensure documentation reflects progress or changes since the initial encounter.

Cervicalgia

Billable Code
M54.2
Billable

Applicable To

  • • Chronic neck pain

Important Notes

  • • Document chronicity and failed treatments.
Ancillary Codes

Additional codes that may be used with this diagnosis

G89.11

Acute pain due to trauma

Use when pain management is the primary focus of the visit.

Frequently Asked Questions

What is the ICD-10 code for cervical strain?

The ICD-10 code for cervical strain is S16.1XXA for initial encounters and S16.1XXD for subsequent encounters.

How do you code a chronic cervical strain?

For chronic cervical strain, use M54.2 for cervicalgia, indicating chronic neck pain.

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