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Finding Strain and Sprains in ICD-10-CM

By:  Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Published:  October 20th, 2015

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.

 

0 Head (S00-S09)
1 Neck (S10-S19)
2 Thorax (S20-S29)
3 Abdomen, lumbar spine and pelvis (S30-S39)
4 Shoulder/upper arm (S40-S49)
5 Elbow/forearm (S50-S59)
6 Wrist, hand, fingers (S60-S69)
7 Hip/thigh (S70-S79)
8 Knee/lower leg (S80-S89)
9 Ankle, foot, toes (S90-S99)

 

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

  • Remember a STRAIN is a muscle, fascia and tendon

         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.

                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:  The 7th character indicates the phase of treatment. 

    The character “A ”, initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician. Guideline 19.a

    References:

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