Pediatric Coding Alert

Question: We had a patient report with a shoulder muscle strain that would not go away two days after a high school football practice. Our provider examined him and sent him home with medication and an ice pack. What diagnosis code should I use for this, and what procedure code(s) can I use in addition to an evaluation and management (E/M) service?

Codify Subscriber

Answer: The ICD-10 index directs you to code muscle strains by going to injury ⇒ muscle by site ⇒ strain. That leads you to the injury code group S46.91- (Strain of unspecified muscle, fascia and tendon at shoulder and upper arm level), where you will choose the appropriate sixth and seventh digits depending on the laterality of the injury and the episode of care. So, for an initial encounter for a muscle strain to the right shoulder, you would code S46.911A (Strain of unspecified muscle, fascia and tendon at shoulder and upper arm level, right arm, initial encounter).

For procedure codes, you should only bill for the E/M service with 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). While it might be tempting to add 97010 (Application of a modality to 1 or more areas; hot or cold packs) for the ice pack, this physical therapy procedure is regarded as a bundled service by Medicare and most payers that follow Medicare guidelines. Even though the National Correct Coding Initiative (NCCI, or CCI) does not list 97010 and 99201-99215 as a code pair, the application of an ice pack to the injury is seen as such a minor procedure that it is regarded as a component part of the service.