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  5. Injury of muscle, fascia and tendon at neck level (S16)

Injury of muscle, fascia and tendon at neck level (S16)

The ICD-10 code section S16 covers injuries to muscles, fascia, and tendons located at the neck level. These codes specify the type of injury; such as strains, lacerations, other specified injuries, or unspecified injuries; and the stage of treatment, including initial encounters, subsequent encounters, and sequelae (complications or conditions following the initial injury).

For example, the code S16.1XXA represents an initial encounter for a strain of muscle, fascia, or tendon at the neck and includes synonyms like "strain of tendon of neck" and "injury of muscle of neck." Similarly, S16.2XXA is used for lacerations to these neck tissues during the first visit, also known as "laceration of fascia of neck" or "laceration of muscle of neck." Other codes within this section classify injuries that are either specifically identified or remain unspecified but involve soft tissues of the neck region. This detailed coding structure helps medical coders accurately document and differentiate the nature and timing of neck muscle and tendon injuries.

  • Injury, poisoning and certain other consequences of external causes (S00–T88)

    • Injuries to the neck (S10-S19)

        • Injury of muscle, fascia and tendon at neck level (S16)

        • S16 Injury of muscle, fascia and tendon at neck level
        • S16.1 Strain of muscle, fascia and tendon at neck level
        • S16.1XXA Strain of muscle, fascia and tendon at neck level, initial encounter
        • S16.1XXD Strain of muscle, fascia and tendon at neck level, subsequent encounter
        • S16.1XXS Strain of muscle, fascia and tendon at neck level, sequela
        • S16.2 Laceration of muscle, fascia and tendon at neck level
        • S16.2XXA Laceration of muscle, fascia and tendon at neck level, initial encounter
        • S16.2XXD Laceration of muscle, fascia and tendon at neck level, subsequent encounter
        • S16.2XXS Laceration of muscle, fascia and tendon at neck level, sequela
        • S16.8 Other specified injury of muscle, fascia and tendon at neck level
        • S16.8XXA Other specified injury of muscle, fascia and tendon at neck level, initial encounter
        • S16.8XXD Other specified injury of muscle, fascia and tendon at neck level, subsequent encounter
        • S16.8XXS Other specified injury of muscle, fascia and tendon at neck level, sequela
        • S16.9 Unspecified injury of muscle, fascia and tendon at neck level
        • S16.9XXA Unspecified injury of muscle, fascia and tendon at neck level, initial encounter
        • S16.9XXD Unspecified injury of muscle, fascia and tendon at neck level, subsequent encounter
        • S16.9XXS Unspecified injury of muscle, fascia and tendon at neck level, sequela

Instructional Notations

Code Also

A "code also" note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.

  • any associated open wound S11

Type 2 Excludes

A type 2 excludes note represents "Not included here". An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.

  • sprain of joint or ligament at neck level S13.9

7th Character Note

Certain ICD-10-CM categories have applicable 7th characters. The applicable 7th character is required for all codes within the category, or as the notes in the Tabular List instruct. The 7th character must always be the 7th character in the data field. If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.

  • The appropriate 7th character is to be added to each code from category S16

7th Character

Indicates that a seventh character is to be assigned to codes in a subcategory.

  • A - initial encounter
  • D - subsequent encounter
  • S - sequela