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Home/Diagnosis/ICD-10 Coding for Low Back Strain

ICD-10 Coding for Low Back Strain

S39.012A
S39.012D
S39.012S

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

Also Known as:
Lumbar Strain
Lower Back Muscle Strain
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Key Information: ICD-10 Coding for Low Back Strain

Essential facts and insights about ICD-10 Coding for Low Back 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.

Primary ICD-10-CM Codes

Strain of muscle, fascia and tendon of lower back, initial encounter

Billable Code
S39.012A
Billable

Diagnostic Criteria

clinical:
  • • Presence of traumatic mechanism and muscle tenderness
coding:
  • • Initial encounter for acute strain
documentation:
  • • Detailed mechanism of injury and physical exam findings

Applicable To

  • • Acute low back strain

Important Notes

  • • Ensure documentation specifies strain and not just pain.

Strain of muscle, fascia and tendon of lower back, subsequent encounter

Billable Code
S39.012D
Billable

Applicable To

  • • Follow-up care for low back strain

Important Notes

  • • Ensure continuity of care documentation.

Strain of muscle, fascia and tendon of lower back, sequela

Billable Code
S39.012S
Billable

Applicable To

  • • Chronic weakness post-strain

Important Notes

  • • Document residual effects clearly.
Ancillary Codes

Additional codes that may be used with this diagnosis

Y93.D1

Activity, lifting

Use for documenting the activity leading to the strain in occupational cases.

Frequently Asked Questions

What is the ICD-10 code for low back strain?

The ICD-10 code for low back strain is S39.012A for initial encounters, S39.012D for subsequent encounters, and S39.012S for sequela.

How do you code a low back strain?

Code low back strain using S39.012A for initial, S39.012D for follow-up, and S39.012S for sequela, ensuring documentation specifies the mechanism of injury.

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