Back Injury ICD-10-CM Codes

What ICD-10 codes are used for back injury?

The coding of back injuries is detailed and specific within the ICD-10 framework. Here are just some of the most commonly utilized codes:

• S39.002A - Unspecified injury of the lower back muscle, fascia, and tendon, initial encounter: Refers to general lower back injuries where specific details might not be known. It can be used in initial diagnoses where the injury type is undetermined.
• S39.82XA - Other specified lower back injuries, initial encounter: Utilized for particular injuries in the lower back, like strains or sprains, where more information about the injury type is known.
• S30.91XA - Unspecified superficial injury of lower back and pelvis, initial encounter: It refers to an unspecified superficial injury (like a bruise or scrape) to the lower back and pelvis.
• S39.92XS - Unspecified injury of lower back, sequela: This code pertains to unspecified lower back injuries with ongoing effects or complications. It is particularly useful for chronic conditions.
• S29.002A - Unspecified injury of muscle and tendon of the back wall of thorax, initial encounter: This is a broader code that encompasses unspecified injuries to the back wall of the thorax, including muscles and tendons.

These codes allow healthcare providers to define and categorize different back injuries. Accurate coding is essential for both treatment planning and insurance billing.

Which back injury ICD codes are billable?

All listed codes are billable.

Clinical information

Back injuries vary significantly in both location and severity. To help healthcare providers accurately document and treat these conditions, ICD-10 codes provide a structured way to describe each aspect of a patient’s injury.  

Location specificity

ICD-10 codes distinguish between injuries based on the region of the back involved. Injuries to the lower back typically affect the lumbar spine and surrounding muscles or tendons. These are among the most common back injuries and are often caused by improper lifting, overuse, or sudden movements.

In contrast, injuries involving the upper back, especially those associated with the thoracic spine or back wall of the thorax, can result from trauma, poor posture, or repetitive stress.

Severity of injury

The coding system also conveys the severity or type of back injury. A fracture, for instance, refers to a break in one or more vertebrae and may range from a simple compression fracture to more complex or displaced breaks.

On the other hand, a strain involves the overstretching or tearing of muscles or tendons in the back. This type of injury is common in individuals who perform heavy lifting or sudden twisting motions and is usually managed through rest, physical therapy, and pain relief measures.

Chronic and long-term conditions

ICD-10 also accounts for the long-term consequences of back injuries. A sequela (S) refers to a condition that arises as a direct result of a previous injury, such as nerve damage, reduced mobility, or persistent stiffness following an earlier trauma. You might also encounter other 7th characters in coding aside from S, such as A (initial encounter) and D for subsequent encounter.

Similarly, chronic pain is used to describe ongoing discomfort that persists even after the initial injury has healed. These codes help clinicians differentiate between an acute injury and its longer-term impact, which is essential for ongoing care, treatment planning, and insurance documentation.

Synonyms include

• Back strain
• Lumbar injury
• Spinal cord famage
• Thoracic muscle injury
• Lower back sprain
• Lumbar region injury
• Back and pelvis unspecified injury
• Other specified injuries of the back