Coding Strain and Sprains in ICD-10-CM

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Oct 20th, 2015 - Reviewed/Updated Jun 17th

There has been some confusion about Strain vs. Strain and how to find them in ICD-10-CM. They are found in two separate code ranges, and the Injury is 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 the rotator cuff capsule, it is reported with the 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 a “Strain of right rotator cuff of the 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:  The 7th character indicates the phase of treatment.