Home Health ICD-9/ICD-10 Alert

READER QUESTIONS:

Look To Sprain Codes For Muscle Tear

Question: We received a referral for physical therapy. The patient has a right gluteus medius tear and the doctor has referred him for gait training. I plan to list V57.1 (Other physical therapy) as primary, but how should I code for the tear?


North Carolina Subscriber


Answer: A torn muscle is considered a sprain. The gluteus medius is also known as the hip abductor (the muscle used to move the leg out). The correct code is 843.8 (Sprains and strains of hip and thigh, other specified sites of hip and thigh).