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ICD-10 Coding for Gastrocnemius Tear(S86.111A)

Complete ICD-10-CM coding and documentation guide for Gastrocnemius Tear. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Calf Muscle TearGastrocnemius Muscle Strain

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Related ICD-10 Code Ranges

Complete code families applicable to Gastrocnemius Tear

S86.1Primary Range

Injury of other muscles and tendons at lower leg level

This range includes codes for injuries to the gastrocnemius muscle, specifying laterality and encounter type.

S81

Open wound of lower leg

Used when there is an open wound associated with the gastrocnemius tear.

Key Information: ICD-10 code for gastrocnemius tear

Essential facts and insights about Gastrocnemius Tear

The ICD-10 code for a gastrocnemius tear is S86.111A, indicating a strain of the right leg, initial encounter.

Primary ICD-10-CM Code for gastrocnemius tear

S86.111A
Strain of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter
Billable Code

Decision Criteria

clinical Criteria

  • Presence of sudden calf pain and imaging confirmation

documentation Criteria

  • Detailed description of injury mechanism and location

Applicable To

  • Acute tear of gastrocnemius muscle

Excludes

  • Achilles tendon injury (S86.0-)

Clinical Validation Requirements

  • Sudden 'pop' in calf
  • Pain at musculotendinous junction
  • Ultrasound/MRI confirmation

Code-Specific Risks

  • Misclassification as unspecified muscle strain

Coding Notes

  • Ensure laterality and encounter type are correctly documented.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Open wound of lower leg

S81.0
Use if there is an open wound associated with the tear.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Injury of Achilles tendon

S86.0
Pain located at the Achilles tendon rather than the mid-calf.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Gastrocnemius Tear to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S86.111A.

Impact

Clinical: Leads to incorrect treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.

Mitigation Strategy

Always document the side of the body affected., Use templates that prompt for laterality.

Impact

Reimbursement: May lead to incorrect DRG assignment and reimbursement issues., Compliance: Non-compliance with coding standards., Data Quality: Decreases accuracy of clinical data.

Mitigation Strategy

Always specify the muscle and laterality in documentation to use the correct code.

Impact

Incorrect use of encounter type characters can lead to audit flags.

Mitigation Strategy

Educate staff on proper use of 'A', 'D', 'S' characters.

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 Gastrocnemius Tear, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Gastrocnemius Tear

Use these documentation templates to ensure complete and accurate documentation for Gastrocnemius Tear. These templates include all required elements for proper coding and billing.

Initial Encounter for Gastrocnemius Tear

Specialty: Orthopedics

Required Elements

  • Patient history
  • Mechanism of injury
  • Physical exam findings
  • Imaging results
  • Treatment plan

Example Documentation

Patient presents with acute right calf pain after tennis match. Ultrasound confirms tear at medial gastrocnemius. Plan includes rest and physical therapy.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has calf pain.
Good Documentation Example
Patient reports acute right calf pain with a 'pop' sound during tennis. Ultrasound shows tear at medial gastrocnemius.
Explanation
The good example provides specific details about the injury and confirms it with imaging.

Need help with ICD-10 coding for Gastrocnemius Tear? Ask your questions below.

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