ICD-10-CM Billable Code

S76.311

Strain of muscle, fascia and tendon of the posterior muscle group at thigh level, right thigh

Clinical Classification Guidelines

Medical Intelligence & Overview

The ICD-10 code S76.311 refers to a muscle strain involving the posterior muscle group of the right thigh. This type of injury occurs when muscle fibers are overstretched or torn, often resulting from sudden movements or direct trauma. It is a common injury among athletes, active individuals, and those involved in physically demanding activities. Recognizing the symptoms and understanding the causes can help in managing and recovering from this condition.

Causes & Symptoms

Clinical Causes: Sudden acceleration or deceleration during physical activity Quick directional changes while running or jumping Direct blow or trauma to the thigh Overuse or repetitive strain in the thigh muscles Insufficient warm-up or stretching before activity Muscle fatigue and weakness Improper technique during sports or exercise

Key Symptoms: Sudden sharp pain in the back of the thigh Tenderness and soreness when touching the area Swelling or bruising around the thigh Muscle weakness or difficulty moving the leg Stiffness and reduced range of motion A feeling of tightness or tension in the thigh muscles Discomfort that worsens with movement or activity

Diagnostic & Treatment

Diagnosis Path: Healthcare providers typically perform a physical examination to assess tenderness, swelling, and range of motion. Imaging tests such as ultrasound or MRI may be ordered to confirm the extent of muscle injury and rule out other conditions like tears or fractures. Proper diagnosis helps determine the appropriate treatment plan and aids in recovery.

Treatment Protocols: Treatment usually involves a combination of rest, ice application to reduce swelling, compression, and elevation (R.I.C.E. method). Pain relievers or anti-inflammatory medications might be suggested to alleviate discomfort. Gradual rehabilitation exercises focused on stretching and strengthening the thigh muscles are essential for recovery. In severe cases, physical therapy or medical interventions may be needed. Returning to normal activities should be guided by pain resolution and medical advice.

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is S76.311 a billable ICD-10 code?
Yes, S76.311 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report S76.311?
Clinical documentation must specify the nature of Strain of muscle, fascia and tendon of the posterior muscle group at thigh level, right thigh and any associated comorbidities for accurate reporting.

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