ICD-10 Coding for Muscle Strain(S76.011A, S76.312A)
Complete ICD-10-CM coding and documentation guide for Muscle Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Muscle Strain
S76.0-S76.3Primary Range
Injury of muscle, fascia and tendon at hip and thigh level
This range covers the most common sites for muscle strains, including the hip, thigh, and lower leg.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S76.011A | Strain of muscle, fascia and tendon of right thigh, initial encounter | Use for initial encounter of a right thigh muscle strain with clear documentation of injury mechanism. |
|
| S76.312A | Strain of muscle, fascia and tendon of posterior muscle group at thigh level, left thigh, initial encounter | Use for initial encounter of a left posterior thigh muscle strain with imaging confirmation. |
|
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 muscle strain
Essential facts and insights about Muscle Strain
Primary ICD-10-CM Codes for muscle strain
Decision Criteria
clinical Criteria
- Presence of localized pain and mechanism of injury
Applicable To
- Right thigh muscle strain
Excludes
- Sprain of right thigh
Clinical Validation Requirements
- Localized pain and restricted range of motion
- Mechanism of injury such as sprinting or lifting
Code-Specific Risks
- Confusion with sprain codes
Coding Notes
- Ensure documentation specifies laterality and encounter type.
S76.312A - Strain of muscle, fascia and tendon of posterior muscle group at thigh level, left thigh, initial encounter
Use for initial encounter of a left posterior thigh muscle strain with imaging confirmation.
Applicable To
- Left posterior thigh muscle strain
Excludes
- Sprain of left thigh
Clinical Validation Requirements
- MRI showing partial fiber disruption
- Palpable defect in muscle
Coding Notes
Document imaging findings to support the grade of strain.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Sprain of anterior cruciate ligament of right knee, initial encounter
S83.511AStrain of muscle, fascia and tendon of right thigh, initial encounter
S76.011ADocumentation & Coding Risks
Avoid these common documentation and coding issues when documenting Muscle Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S76.011A.
Impact
Clinical: Leads to incomplete clinical records., Regulatory: Non-compliance with ICD-10 coding standards., Financial: Potential claim denials due to unspecified coding.
Mitigation Strategy
Always document the side of the body affected., Use templates that prompt for laterality.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Misclassification affects compliance with coding guidelines., Data Quality: Impacts the accuracy of clinical data and statistics.
Mitigation Strategy
Ensure documentation specifies whether the injury involves muscle/tendon (strain) or ligament/joint (sprain).
Impact
Failure to specify encounter type can lead to audit flags.
Mitigation Strategy
Use standardized templates that include encounter type fields.
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 Muscle Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Muscle Strain
Use these documentation templates to ensure complete and accurate documentation for Muscle Strain. These templates include all required elements for proper coding and billing.
Acute muscle strain in emergency department
Specialty: Emergency MedicineRequired Elements
- Patient's subjective description of pain
- Objective findings including ROM and palpation
- Assessment with specific ICD-10 code
- Plan including treatment and follow-up
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Muscle Strain? Ask your questions below.