S16.1XXD - Strain of muscle, fascia and tendon at neck level, subsequent encounter
| ICD-10: | S16.1XXD |
| Short Description: | Strain of muscle, fascia and tendon at neck level, subs |
| Long Description: | Strain of muscle, fascia and tendon at neck level, subsequent encounter |
| Status: | Valid for Submission |
| Version: | ICD-10-CM 2023 |
| Code Classification: |
S16.1XXD is a billable ICD-10 code used to specify a medical diagnosis of strain of muscle, fascia and tendon at neck level, subsequent encounter. The code is valid during the fiscal year 2023 from October 01, 2022 through September 30, 2023 for the submission of HIPAA-covered transactions. The code is exempt from present on admission (POA) reporting for inpatient admissions to general acute care hospitals.
S16.1XXD is a subsequent encounter code, includes a 7th character and should be used after the patient has completed active treatment for a condition like strain of muscle fascia and tendon at neck level. According to ICD-10-CM Guidelines a "subsequent encounter" occurs when the patient is receiving routine care for the condition during the healing or recovery phase of treatment. Subsequent diagnosis codes are appropriate during the recovery phase, no matter how many times the patient has seen the provider for this condition. If the provider needs to adjust the patient's care plan due to a setback or other complication, the encounter becomes active again.
Approximate Synonyms
The following clinical terms are approximate synonyms or lay terms that might be used to identify the correct diagnosis code:
- Dislocations, sprains and strains involving head with neck
- Dislocations, sprains and strains involving multiple body regions
- Dislocations/sprains/strains
- Injury of muscle of neck
- Injury of tendon of neck
- Kinematic imbalance due to suboccipital strain
- Rupture of tendon of head and neck
- Strain of fascia of neck
- Strain of neck muscle
- Strain of tendon of head and neck
- Strain of tendon of head and neck
- Strain of tendon of neck
Coding Guidelines
The appropriate 7th character is to be added to each code from block Injury of muscle, fascia and tendon at neck level (S16). Use the following options for the aplicable episode of care:
- A - initial encounter
- D - subsequent encounter
- S - sequela
Present on Admission (POA)
S16.1XXD is exempt from POA reporting - The Present on Admission (POA) indicator is used for diagnosis codes included in claims involving inpatient admissions to general acute care hospitals. POA indicators must be reported to CMS on each claim to facilitate the grouping of diagnoses codes into the proper Diagnostic Related Groups (DRG). CMS publishes a listing of specific diagnosis codes that are exempt from the POA reporting requirement. Review other POA exempt codes here.
CMS POA Indicator Options and Definitions
| POA Indicator Code | POA Reason for Code | CMS will pay the CC/MCC DRG? |
|---|---|---|
| Y | Diagnosis was present at time of inpatient admission. | YES |
| N | Diagnosis was not present at time of inpatient admission. | NO |
| U | Documentation insufficient to determine if the condition was present at the time of inpatient admission. | NO |
| W | Clinically undetermined - unable to clinically determine whether the condition was present at the time of inpatient admission. | YES |
| 1 | Unreported/Not used - Exempt from POA reporting. | NO |
Convert to ICD-9 Code
| Source ICD-10 Code | Target ICD-9 Code | |
|---|---|---|
| S16.1XXD | V58.89 - Other specfied aftercare | |
| Approximate Flag - The approximate mapping means there is not an exact match between the ICD-10 and ICD-9 codes and the mapped code is not a precise representation of the original code. | ||
Patient Education
Neck Injuries and Disorders
Any part of your neck - muscles, bones, joints, tendons, ligaments, or nerves - can cause neck problems. Neck pain is very common. Pain may also come from your shoulder, jaw, head, or upper arms.
Muscle strain or tension often causes neck pain. The problem is usually overuse, such as from sitting at a computer for too long. Sometimes you can strain your neck muscles from sleeping in an awkward position or overdoing it during exercise. Falls or accidents, including car accidents, are another common cause of neck pain. Whiplash, a soft tissue injury to the neck, is also called neck sprain or strain.
Treatment depends on the cause, but may include applying ice, taking pain relievers, getting physical therapy or wearing a cervical collar. You rarely need surgery.
[Learn More in MedlinePlus]
Sprains and Strains
A sprain is a stretched or torn ligament. Ligaments are tissues that connect bones at a joint. Falling, twisting, or getting hit can all cause a sprain. Ankle and wrist sprains are common. Symptoms include pain, swelling, bruising, and being unable to move your joint. You might feel a pop or tear when the injury happens.
A strain is a stretched or torn muscle or tendon. Tendons are tissues that connect muscle to bone. Twisting or pulling these tissues can cause a strain. Strains can happen suddenly or develop over time. Back and hamstring muscle strains are common. Many people get strains playing sports. Symptoms include pain, muscle spasms, swelling, and trouble moving the muscle.
At first, treatment of both sprains and strains usually involves resting the injured area, icing it, wearing a bandage or device that compresses the area, and medicines. Later treatment might include exercise and physical therapy.
NIH: National Institute of Arthritis and Musculoskeletal and Skin Diseases
[Learn More in MedlinePlus]
Code History
- FY 2023 - No Change, effective from 10/1/2022 through 9/30/2023
- FY 2022 - No Change, effective from 10/1/2021 through 9/30/2022
- FY 2021 - No Change, effective from 10/1/2020 through 9/30/2021
- FY 2020 - No Change, effective from 10/1/2019 through 9/30/2020
- FY 2019 - No Change, effective from 10/1/2018 through 9/30/2019
- FY 2018 - No Change, effective from 10/1/2017 through 9/30/2018
- FY 2017 - No Change, effective from 10/1/2016 through 9/30/2017
- FY 2016 - New Code, effective from 10/1/2015 through 9/30/2016 (First year ICD-10-CM implemented into the HIPAA code set)
