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ICD-10 Coding for Calf Strain(S86.11, S86.21)

Complete ICD-10-CM coding and documentation guide for Calf Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Gastrocnemius StrainSoleus StrainTennis Leg

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Related ICD-10 Code Ranges

Complete code families applicable to Calf Strain

S86.0-S86.9Primary Range

Injury of muscle, fascia and tendon at lower leg level

This range includes all injuries to the muscles, fascia, and tendons of the lower leg, which encompasses calf strains.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
S86.11Strain of posterior muscle group at lower leg levelUse when the strain is confirmed in the posterior muscle group of the lower leg.
  • Tenderness along posteromedial calf
  • Positive Thompson test
  • Inability to perform single-leg heel raise
S86.21Strain of anterior muscle group at lower leg levelUse when the strain is confirmed in the anterior muscle group of the lower leg.
  • Pain on dorsiflexion against resistance
  • Swelling over anterior compartment

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for calf strain

Essential facts and insights about Calf Strain

The ICD-10 code for a calf strain is S86.11 for the posterior muscle group and S86.21 for the anterior muscle group.

Primary ICD-10-CM Codes for calf strain

S86.11
Strain of posterior muscle group at lower leg level
Non-billable Code

Decision Criteria

clinical Criteria

  • Presence of tenderness and positive Thompson test

documentation Criteria

  • Documentation of specific muscle group involved

Applicable To

  • Gastrocnemius strain
  • Soleus strain

Excludes

  • Ankle injuries (S96.-)
  • Knee sprains (S83.-)

Clinical Validation Requirements

  • Tenderness along posteromedial calf
  • Positive Thompson test
  • Inability to perform single-leg heel raise

Code-Specific Risks

  • Confusion with ankle or knee injuries
  • Misclassification without specific muscle identification

Coding Notes

  • Ensure documentation specifies the exact muscle involved and the mechanism of injury.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Open wound of lower leg

S81.-
Use when there is an open wound associated with the calf strain.

Fall from playground equipment

W09.8xxA
Use as an external cause code if the injury resulted from a fall.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Injury of muscle and tendon at ankle and foot level

S96.-
Use S96.- for injuries located at the ankle or foot, not the lower leg.

Sprain and strain of joints and ligaments of knee

S83.-
Use S83.- for injuries involving the knee, not the lower leg.

Strain of posterior muscle group at lower leg level

S86.11
Use S86.11 for posterior muscle group strains, not anterior.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Calf Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S86.11.

Impact

Clinical: Leads to less precise clinical data., Regulatory: May result in audit issues due to lack of specificity., Financial: Can affect reimbursement rates.

Mitigation Strategy

Ensure documentation is detailed and specific., Use specific codes whenever possible.

Impact

Reimbursement: Incorrect coding can lead to denied claims or incorrect reimbursement., Compliance: Using incorrect codes can result in compliance issues during audits., Data Quality: Misclassification affects the accuracy of clinical data.

Mitigation Strategy

Verify the location of the injury and use appropriate codes for lower leg injuries.

Impact

Frequent use of unspecified codes can trigger audits.

Mitigation Strategy

Ensure detailed documentation and use specific codes.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Calf Strain, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Calf Strain

Use these documentation templates to ensure complete and accurate documentation for Calf Strain. These templates include all required elements for proper coding and billing.

Emergency Department Visit for Calf Strain

Specialty: Emergency Medicine

Required Elements

  • Mechanism of injury
  • Specific muscle group involved
  • Physical exam findings
  • Imaging results if available

Example Documentation

Patient presents with sudden onset of medial calf pain during a tennis serve. Exam reveals tenderness over the medial gastrocnemius with a positive Thompson test.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient reports calf pain.
Good Documentation Example
Patient reports acute onset of medial calf pain during tennis serve with tenderness over medial gastrocnemius and positive Thompson test.
Explanation
The good example provides specific details about the mechanism and location of the injury, which are necessary for accurate coding.

Need help with ICD-10 coding for Calf Strain? Ask your questions below.

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