ICD-10 Coding for Trapezius Strain(S46.819A, S29.012A)
Complete ICD-10-CM coding and documentation guide for Trapezius Strain. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Trapezius Strain
S46.8Primary Range
Strain of other muscles, fascia and tendons at shoulder and upper arm level
Covers strains involving the upper trapezius muscle, particularly near the shoulder girdle.
Strain of muscle and tendon of back wall of thorax
Applicable for strains of the mid to lower trapezius muscle located in the thoracic region.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| S46.819A | Strain of other muscles, fascia and tendons at shoulder/upper arm, unspecified arm, initial encounter | Use when the strain is localized to the upper trapezius near the shoulder girdle. |
|
| S29.012A | Strain of muscle/tendon of back wall of thorax, initial encounter | Use for strains affecting the mid to lower trapezius in the thoracic region. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for trapezius strain
Essential facts and insights about Trapezius Strain
Primary ICD-10-CM Codes for trapezius strain
Decision Criteria
clinical Criteria
- Pain and tenderness localized to the upper trapezius muscle.
Applicable To
- Upper trapezius strain near shoulder
Excludes
- Cervical strain
- Thoracic strain
Clinical Validation Requirements
- Pain localized to upper trapezius near acromioclavicular joint
- Limited shoulder elevation
Code-Specific Risks
- Incorrect laterality documentation
- Misclassification as a back strain
Coding Notes
- Ensure laterality is documented if known; otherwise, use unspecified code.
S29.012A - Strain of muscle/tendon of back wall of thorax, initial encounter
Use for strains affecting the mid to lower trapezius in the thoracic region.
Applicable To
- Mid/lower trapezius strain
Excludes
- Upper trapezius strain
- Cervical strain
Clinical Validation Requirements
- Pain with thoracic spine movement
- Ultrasound showing partial tear
Coding Notes
Ensure documentation specifies the thoracic region involvement.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Trapezius Strain to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code S46.819A.
Impact
Clinical: Leads to vague clinical documentation., Regulatory: Non-compliance with ICD-10 specificity requirements., Financial: Potential for denied claims due to lack of specificity.
Mitigation Strategy
Always document laterality and specific muscle involvement., Use specific codes whenever possible.
Impact
Reimbursement: Potential for reduced reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines requiring specificity., Data Quality: Decreased accuracy in patient records.
Mitigation Strategy
Document and code the specific side (right or left) if known.
Impact
Risk of audits due to use of unspecified codes.
Mitigation Strategy
Ensure documentation includes specific details such as laterality and muscle location.
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 Trapezius Strain, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Trapezius Strain
Use these documentation templates to ensure complete and accurate documentation for Trapezius Strain. These templates include all required elements for proper coding and billing.
Acute trapezius strain in emergency department
Specialty: Emergency MedicineRequired Elements
- Pain location and severity
- Physical exam findings
- Imaging results if applicable
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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