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

ICD-10 Coding for Lower Back Strain

S39.012A
S39.012D

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

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

Essential facts and insights about ICD-10 Coding for Lower 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 muscle tenderness and spasm
documentation:
  • • Detailed mechanism of injury

Applicable To

  • • Acute lower back strain

Important Notes

  • • Ensure to specify the encounter type with the appropriate 7th character.

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

Billable Code
S39.012D
Billable

Diagnostic Criteria

clinical:
  • • Ongoing symptoms post initial treatment
  • • Continued muscle tenderness or spasm

Applicable To

  • • Follow-up for lower back strain

Important Notes

  • • Ensure to specify the encounter type with the appropriate 7th character.
Ancillary Codes

Additional codes that may be used with this diagnosis

W50.XXXA

Accidental overexertion from lifting

Use to document the mechanism of injury.

W50.XXXD

Accidental overexertion from lifting, subsequent encounter

Use to document the mechanism of injury in follow-up visits.

Frequently Asked Questions

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

The ICD-10 code for lower back strain is S39.012-, with a 7th character to specify the encounter type.

How do you document a lower back strain?

Document the mechanism of injury, physical exam findings like tenderness and spasm, and specify the encounter type.

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