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Home/Diagnosis/ICD-10 Coding for Strain

ICD-10 Coding for Strain

S16.1XXA

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

Also Known as:
Muscle Strain
Tendon Strain
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Key Information: ICD-10 Coding for Strain

Essential facts and insights about ICD-10 Coding for Strain

Use ICD-10 code S16.1XXA for strain of muscle, fascia and tendon at neck level, initial encounter, ensuring proper documentation in clinical notes.

Primary ICD-10-CM Codes

Strain of muscle, fascia and tendon at neck level, initial encounter

Billable Code
S16.1XXA
Billable

Diagnostic Criteria

clinical:
  • • Presence of muscle tenderness and limited motion
documentation:
  • • Documentation of specific muscle and encounter type

Applicable To

  • • Cervical strain

Important Notes

  • • Ensure documentation specifies the exact muscle and encounter type.
Ancillary Codes

Additional codes that may be used with this diagnosis

W01.XXXA

Fall on same level from slipping, tripping and stumbling, initial encounter

Use to describe the external cause of the strain.

Frequently Asked Questions

What is the ICD-10 code for a neck strain?

The ICD-10 code for a neck strain is S16.1XXA for an initial encounter. Ensure to include the 7th character for encounter type.

How do you code a muscle strain?

To code a muscle strain, identify the specific muscle and encounter type, then use the appropriate ICD-10 code with a 7th character.

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