Complete ICD-10-CM coding and documentation guide for icd-10 coding for gastrocnemius tear includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Gastrocnemius Tear
Use ICD-10 code S86.111A for strain of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter, ensuring proper documentation in clinical notes.
Additional codes that may be used with this diagnosis
Open wound of lower leg
Use if there is an open wound associated with the tear.
The ICD-10 code for a gastrocnemius tear is S86.111A for a strain of the right leg, initial encounter.
Document the specific muscle, laterality, encounter type, and confirm with imaging. Include details like mechanism of injury and physical exam findings.