Sports, exercise, and everyday activities can lead to soft-tissue injuries of the muscles, ligaments, and tendons. These injuries may result in pain, swelling, bruising, and damage.Coding for these soft-tissue injuries in ICD-10-CM is based on the type of soft-tissue injury, the affected area, laterality, if applicable, and the cause of the injury.
Common Soft-Tissue Injuries and Their CausesAccording to the American Academy of Orthopedic Surgeons, common types of soft-tissue injuries include:
- Contusions (bruises)
SymptomsPain and swelling of the affected area are often the main symptoms. However, symptoms are based on the specific type of soft tissue injury. Other common symptoms include:
- Muscle cramping
- Lump or knot at the injury site
- Joint instability
- Inability to put weight on a limb
Diagnosis and TreatmentPhysicians can diagnose soft-tissue injuries based on the symptoms, cause of injury, and by physical examination. X-rays or other imaging tests are sometimes needed. Initial treatment for acute soft-tissue injuries generally begins with the RICE protocol (rest, ice, compression, and elevation). Other treatments may include anti-inflammatories, steroid injections, splints, and exercises. Physical therapy may be recommended for more severe acute injuries. If surgery is required, a minimally invasive procedure my be recommended.
Acute Soft-Tissue Injuries in ICD-10-CM
A sprain is a stretch and/or tear of a ligament of a joint.
A sprain is a stretch and/or tear of a ligament of a joint. A ligament is connective tissue that joins the ends of two bones together and stabilizes the joints. A sprain is often caused by a sudden twist or pull and often occurs in the ankles, knees, or wrists. The intensity can vary, but pain, bruising, swelling, and inflammation are common symptoms for sprains.Examples of ICD-10-CM codes for sprain of ankle, knee, and wrist are:
- S93.411A, Sprain of calcaneofibular ligament of right ankle, initial encounter
- S83.522D, Sprain of posterior cruciate ligament of left knee, subsequent encounter
- S63.529S, Sprain of radiocarpal joint of unspecified wrist, sequela
A strain is a stretch or partial or complete tear of the muscle and tendon attachment.
A strain is a stretch or partial or complete tear of the muscle and tendon attachment. Tendons are the fibrous cords of tissue that join the muscles and bones together.Strains are common in the back and leg (usually the hamstring). Certain sports can put athletes at risk of hamstring, hand, or elbow strains. Pain, muscle spasm, muscle weakness, swelling, inflammation, and cramping are symptoms of a strain. Examples of ICD-10-CM codes for strain of back, hamstring, hand, and elbow are:
- S39.012A, Strain of muscle, fascia and tendon of lower back, initial encounter
- S76.311D, Strain of muscle, fascia and tendon of the posterior muscle group at thigh level, right thigh, subsequent encounter
- S66.911S, Strain of unspecified muscle, fascia and tendon at wrist and hand level, right hand, sequela
- S56.812A, Strain of other muscles, fascia and tendons at forearm level, left arm, initial encounter
- “A”, initial encounter, is used for each encounter where the patient is receiving active treatment for the condition.
- “D” subsequent encounter, is used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.
- “S”, sequela, is for use for complications or conditions that arise as a direct result of a condition.
A contusion (bruise) is caused by a hard object striking part of the body once or repeatedly.
A contusion is caused by a hard object striking part of the body once or repeatedly. This blow results in the underlying muscle fibers and connective tissue to crush without breaking the skin. Falling or having the body forced against a hard surface can result in a contusion, a discoloration of the skin caused by bleeding and tissue damage underneath the skin.Examples of ICD-10-CM codes for contusion are:
- S30.0XXA, Contusion of lower back and pelvis, initial encounter
- S20.212D, Contusion of left front wall of thorax, subsequent encounter
- S40.022S, Contusion of left upper arm, sequela
Chronic (Overuse) Soft-Tissue Injuries
Tendinitis is an inflammation or irritation of a tendon or the sheath (the covering of a tendon).
Tendinitis is an inflammation or irritation of a tendon or the sheath (the covering of a tendon). The cause is usually due to repetitive activities or movements that put stress on the joints. Athletes are susceptible to tendinitis in the shoulders, elbows, knees, and ankles. Swelling and pain are common symptoms of tendinitis, which tend to worsen with activity.Examples of codes for tendinitis in the shoulders, elbows, knees, and ankles are:
- M75.21, Bicipital tendinitis, right shoulder
- M77.11, Lateral epicondylitis, right elbow
- M76.50, Patellar tendinitis, unspecified knee
- M65.272, Calcific tendinitis, left ankle and foot
Bursitis is inflammation of the bursa.
Bursitis is inflammation of the bursa. The bursa is a small, fluid-filled sac that is positioned between a bone and soft tissue. It acts as a cushion to help reduce friction. Overuse of a joint is usually the cause of bursitis, but direct trauma can also cause it.Symptoms include swelling and pain around the muscles and bones, especially around the joints. The most common areas where bursitis occurs are in the shoulders, elbows, wrists, hips, knees, and ankles. Bursitis is often experienced in people with tendinitis. Examples of codes for bursitis in the shoulders, wrists, hips, knees, and ankles are:
- M75.52, Bursitis of left shoulder
- M70.11, Bursitis, right hand
- M70.62, Trochanteric bursitis, left hip
- M70.40, Prepatellar bursitis, unspecified knee
- M70.872, Other soft tissue disorders related to use, overuse and pressure, left ankle and foot
Assigning the Right ICD-10-CM Code
Coding QuestionsRead the scenarios below and see if you can assign the primary diagnosis codes. Do not worry about coding the cause of the injuries for this exercise. The answers are provided below.
- A 23-year-old male presents to the emergency department after sustaining an injury to her right wrist. An x-ray of the wrist is taken, and the patient is diagnosed with wrist sprain.
- A patient is seen for her acute back pain due to lumbar strain, initial encounter.
- A 57-year-old female patient is seen in the office today complaining of pain in her left shoulder after falling in the shower. She states her pain level is at a 7/10. On examination, there is a contusion on her left shoulder. No other injures were observed and an x-ray showed no fracture.
- A 30-year-old male who trains for soccer 5 days a week complains of right lower extremity pain. He has not sustained any injury and there is no fracture, but he does have restricted movement. The soccer player is diagnosed with Achilles tendinitis. Patient is prescribed rest, ice, compression, and elevation and told to wear a heel pad.
- Patient is a tennis player who plays on a tennis league. Today she complains of right elbow pain and is diagnosed with olecranon bursitis.
- S63.501A, Unspecified sprain of right wrist, initial encounter. In the Alphabetic Index, look up Sprain (joint) (ligament)/wrist S63.50-. In the Tabular, we can verify the correct code as S63.501A. The patient is receiving active treatment.
- S39.012A, Strain of muscle, fascia and tendon of lower back, initial encounter. A lumbar strain is in the lower back. Look up Strain/lower back S39.012. In the Tabular, we can verify the correct code as S39.012A (initial encounter).
- S40.012A, Contusion of left shoulder. Look up Contusion (skin surface intact)/shoulder S40.01-. In the Tabular, we can verify the correct code as S40.012A. The patient is receiving active treatment.
- M76.61, Achilles tendinitis, right leg. Look up Tendinitis, tendonitis/Achilles M76.6-. In the Tabular, we can verify the correct code as M76.61.
- M70.21, Olecranon bursitis, right elbow. Look up Bursitis/elbow/olecranon M70.2-. In the Tabular, we can verify the correct code as M70.21.