ICD Code S16.1

ICD code S16.1 is a diagnosis code for strain of muscle, fascia, and tendon at the neck level.

1. Presence of pain localized to the neck region following trauma

2. Observable swelling or bruising in the neck area

3. Limited range of motion or stiffness in the neck

4. Palpable tenderness over the cervical muscles

5. Absence of neurological deficits such as numbness or weakness in the arms or legs

6. No evidence of fracture or dislocation on imaging studies

7. History of a specific incident causing hyperflexion, hyperextension, or direct impact to the neck

Relevant CPT codes that may be used to treat ICD code S16.1 include:

- 99201–99215 (Evaluation and Management services)

- 20552 (Injection(s); single or multiple trigger point(s), one or two muscle(s))

- 20553 (Injection(s); single or multiple trigger point(s), three or more muscles)

- 97110 (Therapeutic exercises)

- 97112 (Neuromuscular reeducation)

- 97140 (Manual therapy techniques)

- 97010 (Application of a modality to 1 or more areas; hot or cold packs)

- 97035 (Ultrasound therapy)

- 95851 (Range of motion measurements and report)

- 95852 (Range of motion measurements, each extremity and spine)

These CPT codes are commonly associated with the treatment of ICD code S16.1.

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