S16.1XXA – Strain of muscle, fascia and tendon at neck level, initial encounter
Learn all about the ICD-10-CM code S16.1XXA, which is for the strain of muscle, fascia, and the tendon at the neck level during the initial encounter, including what its clinical description is, if it’s billable or not, what its synonyms are, what other ICD codes are related to it, and a few FAQs.
Fact Checked by Ericka Pingol.
S16.1XXA Diagnosis Code: Strain of muscle, fascia and tendon at neck level, initial encounter
The S16.1XXA is an ICD code that’s included in the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM, for short), and it is used to designate “Strain of muscle, fascia and tendon at neck level, initial encounter.”
This ICD code pertains to the muscle, fascia, and tendons at the neck level being overstretched or torn. Strains are caused by almost the same things as sprains. In the context of the neck area, this is caused by falling, overexertion of the neck during strenuous activities, whiplash, and poor posture, to mention a few.
In this diagnosis code, “initial encounter” means that it’s the first time a patient and their condition were assessed by a certain provider. It doesn’t matter if they’ve been assessed and diagnosed with this before by another provider.
This code should also be given while the patient is actively treated for such strains.
Is S16.1XXA billable?
Yes, this ICD-10-CM code is billable and can be used to indicate a diagnosis for reimbursement.
S16.1XXA Clinical Information
To reiterate, a strain in a neck-level muscle, fascia, or tendon means that it is overstretched or in the worst case, torn. If a patient has a neck-level muscle, fascia, or tendon strain, they will likely have the following symptoms:
- Muscle spasms
- Pain in the neck, especially at the back
- Difficulty moving the neck
- Pain while moving the neck
- Headaches
- Pain that worsens over time, especially if the neck is maintained in one position for too long
The strain of neck-level muscles, fascia, or tendons is normally caused when the neck is overly twisted or pulled, whiplash due to falling or some other accident, poor posture, or strenuous activities like lifting weights or playing sports. Even sleeping awkwardly can cause strains.
The treatment for strains is non-invasive. This involves resting, using a compress (ice, cold, bandaging), and medicine to relieve the pain. Depending on the clinician treating the patient, they may implement treatment plans that involve exercise and physical therapy to rehabilitate the strain.
S16.1XXA synonyms include
- Strain of fascia of neck
- Strain of neck muscle
- Strain of tendon of head and neck
- Strain of tendon of head and neck
- Strain of tendon of neck
Other ICD-10 codes commonly used for neck-level strains
- S16.1 - Strain of muscle, fascia and tendon at neck level
- 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 - Injury of muscle, fascia and tendon at neck level
- 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
- S16.9 - Unspecified injury of muscle, fascia and tendon at neck level
- S16.9XXA - Unspecified injury of muscle, fascia and tendon at neck level, initial encounter
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Commonly asked questions
Yes, this ICD-10 code is billable.
It means that a patient has strains in the neck-level muscles, fascia, and tendons, and it’s the first time a certain provider is handling them.
More often than not, a neck-level strain just needs rest. Sometimes, a compress may be applied, like ice or bandages. If the clinician thinks it’s necessary, then can add exercise and physical therapy to the treatment.
