ICD-10 Guide

Musculoskeletal Strain

ICD-10 Coding for Musculoskeletal Strain(S76.011A, S76.01XA)

PRIMARY SPECIALTYOrthopedics

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Musculoskeletal Strain?

Essential facts and insights about Musculoskeletal Strain

Key Clinical Considerations:

Localized pain and tenderness in the affected area
Swelling or bruising around the injury site
Reduced range of motion or stiffness

Clinical Information

Clinical Criteria & Documentation Requirements

Patient history including mechanism of injury
Detailed physical examination findings
Assessment of pain level and functional limitations

Coding Guidelines

Usage Guidelines & Examples

Ensure correct laterality and encounter type are documented.
Common errors include using non-specific codes or omitting encounter details.

Code Exclusions

Important Exclusions

Fractures, dislocations, and chronic pain conditions
Alternative codes for specific muscle injuries

Specialty Focus

Primary Specialty

Orthopedics

Specialty Applications

Athletes, manual laborers, and elderly populations
Emergency rooms, outpatient clinics, and orthopedic practices

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Include detailed history, physical exam findings, and treatment plan.

Billing considerations?

Ensure accurate coding to reflect the specific site and severity of the strain.

Musculoskeletal Strain

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?

Musculoskeletal Strain

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

Documentation requirements?

Billing considerations?