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ICD-10 Guide
DiagnosesTrapezius Muscle Strain

Trapezius Muscle Strain

ICD-10 Coding for Trapezius Muscle Strain(S46.819A)

PRIMARY SPECIALTYOrthopedics
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Trapezius Muscle Strain?
Essential facts and insights about Trapezius Muscle Strain

Key Clinical Considerations:

  • Localized pain in the upper back and neck region
  • Muscle stiffness and reduced range of motion
  • Swelling or tenderness over the trapezius muscle

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history including onset and duration of symptoms
  • Physical examination findings detailing tenderness and range of motion
  • Imaging results if applicable, such as MRI or X-ray

Coding Guidelines

Usage Guidelines & Examples

  • Usage guidelines: Use specific codes based on the encounter type (initial, subsequent, sequela).
  • Common errors: Misclassifying the strain as a sprain or failing to document the encounter type.

Code Exclusions

Important Exclusions

  • Excluded conditions: Cervical radiculopathy, herniated disc.
  • Alternative codes: Consider M62.830 for muscle strain not specified.

Related ICD-10 Codes

Primary Codes
S16.1XXA
Strain of muscle, fascia and tendon at neck level, initial encounter
Ancillary Codes
Y93.B9
Differential Codes
M54.6
M54.6
for chronic pain without specific muscle injury.

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Orthopedics

Specialty Applications

  • Patient populations: Adults with acute or chronic neck pain.
  • Clinical settings: Orthopedic clinics, physical therapy centers, and urgent care.

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 patient history, physical exam findings, and any imaging results.

Billing considerations?

Ensure accurate coding to reflect the severity and encounter type for proper reimbursement.