ICD Code S39.012A

ICD code S39.012A is a medical classification used to denote a strain of the muscle, fascia, and tendon of the lower back during the initial encounter. This code is part of the International Classification of Diseases, 10th Revision (ICD-10), which is used by healthcare providers to document diagnoses and conditions. The "initial encounter" designation indicates that this code is used for the first time a patient is being treated for this specific injury.

1. Acute Onset of Pain: The patient experiences a sudden onset of pain in the lower back region, which may occur during physical activity or after a specific incident, such as lifting a heavy object.

2. Localized Tenderness: Upon physical examination, there is noticeable tenderness in the lower back area, particularly when pressure is applied to the affected muscles, fascia, or tendons.

3. Limited Range of Motion: The patient exhibits a restricted range of motion in the lower back, often accompanied by stiffness, making it difficult to perform normal activities such as bending or twisting.

4. Muscle Spasms: The presence of involuntary muscle contractions or spasms in the lower back, which may be visible or palpable during a physical examination.

5. Swelling or Bruising: There may be visible signs of swelling or bruising in the lower back area, indicating possible damage to the muscle, fascia, or tendon.

6. Absence of Neurological Symptoms: The patient does not exhibit neurological symptoms such as numbness, tingling, or weakness in the legs, which would suggest a more serious condition like a herniated disc.

7. Initial Encounter: This is the first time the patient is being evaluated and treated for this specific strain, indicating that the injury is in the acute phase and has not been previously addressed in a clinical setting.

For the ICD code S39.012A, which pertains to a strain of muscle, fascia, and tendon of the lower back during an initial encounter, the relevant CPT codes that may be applicable include:

1. 97110 - Therapeutic exercises to develop strength and endurance, range of motion, and flexibility.

2. 97140 - Manual therapy techniques, such as mobilization/manipulation, manual lymphatic drainage, and manual traction.

3. 97112 - Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception.

4. 97032 - Application of a modality to one or more areas; electrical stimulation (manual), each 15 minutes.

5. 97035 - Application of a modality to one or more areas; ultrasound, each 15 minutes.

6. 97530 - Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes.

These CPT codes are commonly used in the treatment of musculoskeletal conditions and may be relevant depending on the specific treatment plan and interventions chosen by the healthcare provider. Always ensure that the selected CPT codes accurately reflect the services provided and are supported by the patient's medical documentation.

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