2022 ICD-10-CM Code S16.9

Unspecified injury of muscle, fascia and tendon at neck level

Version 2021

Not Valid for Submission

ICD-10:S16.9
Short Description:Unsp injury of muscle, fascia and tendon at neck level
Long Description:Unspecified injury of muscle, fascia and tendon at neck level

Code Classification

  • Injury, poisoning and certain other consequences of external causes (S00–T98)
    • Injuries to the neck (S10-S19)
      • Injury of muscle, fascia and tendon at neck level (S16)

S16.9 is a non-specific and non-billable diagnosis code code, consider using a code with a higher level of specificity for a diagnosis of unspecified injury of muscle, fascia and tendon at neck level. The code is not specific and is NOT valid for the year 2022 for the submission of HIPAA-covered transactions. Category or Header define the heading of a category of codes that may be further subdivided by the use of 4th, 5th, 6th or 7th characters.

Unspecified diagnosis codes like S16.9 are acceptable when clinical information is unknown or not available about a particular condition. Although a more specific code is preferable, unspecified codes should be used when such codes most accurately reflect what is known about a patient's condition. Specific diagnosis codes should not be used if not supported by the patient's medical record.

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:

Specific Coding for Unsp injury of muscle, fascia and tendon at neck level

Non-specific codes like S16.9 require more digits to indicate the appropriate level of specificity. Consider using any of the following ICD-10 codes with a higher level of specificity when coding for unsp injury of muscle, fascia and tendon at neck level:

  • BILLABLE CODE - Use S16.9XXA for initial encounter
  • BILLABLE CODE - Use S16.9XXD for subsequent encounter
  • BILLABLE CODE - Use S16.9XXS for sequela

Index to Diseases and Injuries

The Index to Diseases and Injuries is an alphabetical listing of medical terms, with each term mapped to one or more ICD-10 code(s). The following references for the code S16.9 are found in the index:

Information for Patients


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.


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Code History

  • 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)