Finding Strain and Sprains in ICD-10-CM

There has been some confusion on Sprain vs. Strain and how to find them in ICD-10-CM. They are now split in two separate code ranges and Injury is now related to the anatomic location specific to the injury.

 It will help to remember the following information when searching for Strains vs. Sprains

• A strain is an injury found under muscle/tendon/fascia
• A sprain is an injury found under dislocation/ligament/joint

Injuries are listed by site or location, for the next two examples we will look at S6- Wrist, hand, fingers and S4- Shoulder/upper arm.

Search for: Strain of the Flexor tendon of the right index finger

• Remember a STRAIN is a muscle, fascia and tendon

S          Ch. 19 Injury, poisoning and certain other consequences of external causes (S00-T88) 

S6         Injuries to the wrist hand and fingers (S60-S69)

S66       Injury of muscle, fascia and tendon at wrist and hand level

S66.1    Injury of flexor muscle, fascia and tendon of other and unspecified finger at wrist and hand level

S66.11   Strain of flexor muscle, fascia and tendon of other and unspecified finger at wrist and hand level 

S66.110 Strain of flexor muscle, fascia and tendon of right index finger at wrist and hand level 

S66.110A Strain of flexor muscle, fascia and tendon of right index finger at wrist and hand level, initial encounter

Take a look at a rotator cuff tear. If the injury is reported as a Sprain of rotator cuff capsule it is reported with the a code from S43.42-

• Remember a SPRAIN is found under dislocation/ligament/joint

S             Injury

S4           Injury Shoulder/Upper Arm

S43         Dislocation and sprain of joints and ligaments of shoulder girdle

S43.4       Sprain of shoulder joint 

S43.42     Sprain of rotator cuff capsule 

S43.421    Sprain of right rotator cuff capsule 

S43.421A  Sprain of right rotator cuff capsule, initial encounter

If the injury is described as “Strain of right rotator cuff of shoulder”, a code from S46.01 would be reported.

S             Injury

S4           Injury Shoulder/Upper Arm

S46          Injury of muscle, fascia and tendon at shoulder and upper arm level 

S46.0        Injury of muscle(s) and tendon(s) of the rotator cuff of shoulder 

S46.01      Strain of muscle(s) and tendon(s) of the rotator cuff of shoulder 

S46.011     Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder

S46.011A Strain of muscle(s) and tendon(s) of the rotator cuff of right shoulder, initial encounter

Reminder: Do not confuse the “A” -Initial Encounter for the Initial Visit. The initial encounter will be used during the entire time the patient is receiving active treatment for the condition.

ICD-10-CM instructs the provider to code any associated open wound and code to identify any retained foreign body.

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