5 Types of Soft-Tissue Injuries in ICD-10-CM: Noteworthy Coding Tips

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 Causes

According to the American Academy of Orthopedic Surgeons, common types of soft-tissue injuries include:
  • Sprains
  • Strains
  • Contusions (bruises)
  • Tendonitis
  • Bursitis
Injuries to soft tissues in the body can either be acute or chronic. Sprains, strains, and contusions are considered acute soft-tissue injuries. An acute soft-tissue injury is caused by sudden trauma, such as a fall, twist, or blow to the body. Tendonitis and bursitis are considered chronic (overuse) soft-tissue injuries. A chronic soft-tissue injury happens gradually over time and is caused when a particular muscle or joint is repetitively overused and the body is not allowed enough time to heal between the events.

Symptoms

Pain 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
  • Weakness
  • Spasms
  • Lump or knot at the injury site
  • Joint instability
  • Inability to put weight on a limb

Diagnosis and Treatment

Physicians 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

Sprain

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

Strain

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
Sprains and strains of joints and muscles are reported with codes from Chapter 19. Injury, poisoning, and certain other consequences of external causes (S00-T88). They are classified according to anatomical site, laterality, and episode of care. Sprain codes are found with dislocations. Strain codes are found with other. The 7th character identifies the episode of care for that injury.
  • “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.
The placeholder “X” needs to be used in all character positions that do not have a value when a 7th character is required. When reporting for sprains and strains, also use a code from Chapter 20 to report the cause of the injury. If there is any associated open wound documented with the sprain or strain, that too should be coded.

Contusion (Bruise)

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
Contusions are similar to sprains and strains in that they are reported with codes from Chapter 19 and are classified by the anatomical site, laterality, if applicable, and the episode of care. Again, there is an instructional note that indicates the cause of injury should also be reported. According to the ICD-10-CM Official Guidelines for Coding and Reporting (FY2021), “Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site.” For example, a patient sustained both a fracture and a contusion of the left wrist. Only the fracture is coded because it is the more severe injury on the same site (left wrist). If the patient has a fracture of the right wrist and a contusion on the left shoulder, both the fracture of the right wrist and contusion of the left shoulder would be coded.

Chronic (Overuse) Soft-Tissue Injuries

Tendinitis (Tendonitis)

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

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
Tendinitis (tendonitis) and bursitis are reported with codes from Chapter 13. Diseases of the musculoskeletal system and connective tissue (M00-M99). Tendinitis is classified according to the affected body area or the activity that caused the pain, such as golfer’s elbow, and laterality. For example, a patient is diagnosed with Achilles tendinitis. It is found by looking under Tendinitis, tendonitis/Achilles. If the diagnosis is golfer’s elbow, it can be found by looking under Golfer’s elbow – see Epicondylitis, medial/Epicondylitis (elbow)/medial M77.0-. It is further classified as to unspecified, right, and left elbow. Note: There is no 7th character for tendinitis or bursitis. The ICD-10-CM Official Guidelines for Coding and Reporting (FY2021) state, “When coding injuries, assign separate codes for each injury unless there is a combination code provided, in which case the combination code is assigned… The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.”
Before making final code selection for the above soft-tissue injuries, be sure to read all the instructional notes. They all mean something.

Assigning the Right ICD-10-CM Code

Coding Questions

Read 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.
  1. 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.
  2. A patient is seen for her acute back pain due to lumbar strain, initial encounter.
  3. 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.
  4. 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.
  5. Patient is a tennis player who plays on a tennis league. Today she complains of right elbow pain and is diagnosed with olecranon bursitis.

Answers

  1. 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.
  2. 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).
  3. 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.
  4. 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.
  5. 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.
person with soft-tissue injury and coding for this in ICD-10-CM

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2 Comments

  1. Another great post! This is quite helpful information. In particular, I appreciate your pointing out that often when there are two injuries in the same area, only the more serious of the two will get coded. Keep up the great content.

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