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Chiropractic Coding & Compliance Alert

You Be the Coder:

Coding the Second Encounter for a Neck Strain Patient

Question: A patient visits the office for a second time. She has the diagnosis of neck strain. How should we code for this using ICD-10 code?

Michigan Subscriber

Answer: With the given information, you would use the most appropriate injury code such as S16.1 (Strain of muscle, fascia and tendon at neck level).

The second encounter can be incorporated in the code using the seventh character, which is quite useful in injury codes. Here is what the following characters denote:

  • A: Initial encounter
  • D: Subsequent encounter
  • S: Sequela.

Therefore, use S16.1xxD to denote your case. The small “x” represents place holders that may denote further location and laterality respectively, as that is not evident in the information you provided. 

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