Complete ICD-10-CM coding and documentation guide for icd-10 coding for low back muscle strain includes clinical validation requirements, medical necessity guidelines, and coding policies.
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Essential facts and insights about ICD-10 Coding for Low 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.
Additional codes that may be used with this diagnosis
Chronic pain due to trauma
Use if chronic pain persists after strain.
The ICD-10 code for low back muscle strain is S39.012A for initial encounters, S39.012D for subsequent encounters, and S39.012S for sequela.
Document the mechanism of injury, specific muscle involvement, encounter type, and any imaging results to support the diagnosis of low back muscle strain.