Muscle Strain ICD-10-CM Codes | 2023

What ICD-10 Codes are Used for Muscle Strain

ICD-10 codes for muscle strain fall under the S76 category, encompassing various types and locations of muscle injuries. Here are the commonly used Muscle Strain ICD-10 codes, along with clinical descriptions for each code:

• S76.012A - Strain of muscle, fascia, and tendon of right hip, initial encounter: This code treats muscle strain in the right hip caused by sudden movements or lifting heavy objects, leading to pain and discomfort.
• S76.311A - Strain of muscle, fascia, and tendon of left lower leg, initial encounter: Muscle strain in the left lower leg is caused by overuse or physical exertion, resulting in pain and limited mobility.
• S76.011A - Strain of muscle, fascia, and tendon of right thigh, initial encounter: Right thigh muscle strain is common among athletes and causes pain/stiffness.
• S76.22XA - Strain of muscle, fascia, and tendon of left forearm, initial encounter: Left forearm muscle strain can cause discomfort and weakness due to repetitive movements or sudden injury.
• S76.821A - Strain of muscle, fascia, and tendon of the right hand, initial encounter: Right hand muscle strain causes pain, weak grip, and limited dexterity due to repetitive tasks or overuse.
• S76.612A - Strain of muscle, fascia, and tendon of left foot, initial encounter: Uneven surfaces may cause muscle strain in the left foot, leading to pain, swelling, and difficulty walking.
• S76.213A - Strain of muscle, fascia, and right forearm tendon, initial encounter: Code for right forearm muscle strain caused by overexertion or repetitive motions, leading to discomfort and restricted arm movement.
• S76.10XA - Strain of unspecified muscles, fascia, and tendons at thigh level, initial encounter: This code is used when a general strain in the thigh area causes pain and reduced mobility.
• S76.0XXA - Strain of unspecified muscles, fascia, and tendons at hip and thigh level, initial encounter: This code covers unspecified muscle strain in the hip and thigh region, causing pain and discomfort.
• S76.1XXA - Strain of unspecified muscles, fascia, and tendons at lower leg level, initial encounter: Pain and limited movement in the lower leg indicate muscle strain when the specific muscle or tendon is unidentified.

These ICD-10 codes help healthcare providers accurately document and diagnose muscle strain injuries, ensuring appropriate treatment and care for patients experiencing these conditions.

Which Muscle Strain ICD Codes are Billable

Various factors, such as the healthcare provider, insurance policies, and the documentation of the medical necessity of the service, determine the billability of ICD-10 codes for muscle strain. 

However, it is essential to note that the billing of commonly used ICD-10 codes for muscle strain can vary depending on these factors.

• S76.012A - Strain of muscle, fascia, and tendon of right hip, initial encounter: Yes.
• S76.311A - Strain of muscle, fascia, and tendon of left lower leg, initial encounter: Yes. 
• S76.011A - Strain of muscle, fascia, and tendon of right thigh, initial encounter: Yes.
• S76.22XA - Strain of muscle, fascia, and tendon of left forearm, initial encounter: Yes.
• S76.821A - Strain of muscle, fascia, and tendon of the right hand, initial encounter: Yes.
• S76.612A - Strain of muscle, fascia, and tendon of left foot, initial encounter: Yes.
• S76.213A - Strain of muscle, fascia, and right forearm tendon, initial encounter: Yes.
• S76.10XA - Strain of unspecified muscles, fascia, and tendons at thigh level, initial encounter: Yes.
• S76.0XXA - Strain of unspecified muscles, fascia, and tendons at hip and thigh level, initial encounter: Yes.
• S76.1XXA - Strain of unspecified muscles, fascia, and tendons at lower leg level, initial encounter: Yes.

Medical coding and billing are complex, and policies and regulations may vary. Accuracy is crucial to avoid claim denials. Consult with a certified medical coder or healthcare provider for billing and coding guidance.

Clinical Information

• Muscle strain symptoms include pain, swelling, tenderness, and limited range of motion. Weakness, discoloration, and bruising may also occur.
• Muscle strains can result from various factors, including overexertion during physical activities or sports, sudden or forceful movements, inadequate warm-up or stretching, muscle fatigue, and a history of previous muscle injuries, which can increase susceptibility.
• Healthcare providers diagnose muscle strains through a combination of physical examination, which assesses the location and severity of the injury, a review of the patient's medical history and activity level, and imaging studies such as ultrasound, MRI, or X-rays to confirm the extent of damage.
• The treatment approach for muscle strains includes a combination of rest, allowing the muscle to heal; applying ice and compression to reduce inflammation; elevation to minimize swelling; pain relief through over-the-counter or prescription medications; and physical therapy to regain strength and flexibility.
• The recovery period for muscle strains varies depending on the severity of the injury, ranging from a few days to several weeks. 
• Patients typically experience a gradual return to physical activities under medical guidance. They are advised to follow preventive measures, such as proper warm-up and stretching techniques, to avoid future strains.
• If left untreated or managed incorrectly, muscle strains can lead to chronic pain, muscle imbalances, recurring injuries, and reduced muscle function and mobility.
• To prevent muscle strains, individuals should maintain proper conditioning and fitness, warm up before exercise, cool down afterward, use correct techniques during physical activities, pay attention to their body's signals to avoid overexertion, and seek prompt medical attention if they suspect a strain to prevent the worsening of the injury. 
• Understanding these clinical aspects of muscle strain is crucial for healthcare providers and individuals to ensure proper management and prevent complications.

Synonyms Include

• Muscle pull
• Muscle tear
• Muscle sprain
• Muscular injury
• Muscle overexertion