Complete ICD-10-CM coding and documentation guide for icd-10 coding for lower 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 Lower 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
Fall on same level
Use to specify the cause of injury if applicable.
Overexertion
Use when the strain is due to overexertion activities.
The ICD-10 code for lower back muscle strain is S39.012A, used for initial encounters with documented mechanism of injury.
Document the mechanism of injury, specific physical exam findings, and any functional limitations to accurately code a lower back muscle strain.