A U.S. based medical billing outsourcing company with extensive experience, Outsource Strategies International (OSI) provides medical billing and coding services for individual physicians, medical practices, clinics, and hospitals. In today’s podcast, Natalie Tornese, one of our Senior Solutions Managers, discusses the types and treatment options of soft tissue injuries and, how to report the condition.
Hello every one and welcome to our podcast series!
I wanted to talk a little bit about soft tissue injuries.
Soft-tissue injuries (STI) are one of the most common injuries that occur due to sport and exercise activities. The most common tissues injured are the muscles, tendons, and ligaments that connect, support or surround other structures and organs of the body. They are commonly characterized into two types:
Acute injuries which are any type of injury caused by a sudden trauma, such as a fall, twists, or blow to the body. Examples of these include sprains, strains, and contusions.
Overuse injuries which occurs gradually over time, like when a certain activity is repeated, and areas of the body do not have enough time to heal between occurrences. Examples of those include bursitis and tendinitis.
When soft tissue is damaged, there is usually immediate pain along with swelling. Stiffness and bruising may also develop after 24-48 hours which is also very common as a result of the trauma and swelling. However, in the case of moderate to severe soft tissue injuries muscles, and ligaments around the joint, there may be instability experienced, as well, especially to weight-bearing joints like the hip, the knee, the ankle. Both athletes and non-athletes share many similar soft-tissue injuries.
I will include a transcript along with this podcast outlining the related ICD-10 coding for the following conditions.
(ICD-10 codes for Soft-tissue injuries (STI) are:
- M70: Soft tissue disorders related to use, overuse and pressure
- M70.8: Other soft tissue disorders related to use, overuse and pressure
- M70.80 …… of unspecified site
- M70.9: Unspecified soft tissue disorder related to use, overuse and pressure
- M70.90: …… of unspecified site
- M79.9: Soft tissue disorder, unspecified
Five different STI conditions and their ICD-10 codes, that affect our body’s musculoskeletal system, which require clinical care by a physician or other healthcare professional are:
- S73.1: Sprain of hip
- S53.4: Sprain of elbow
- S93.4: Sprain of ankle
- S93.6: Sprain of foot
- S76.01: Strain of muscle, fascia and tendon of hip
- S76.11: Strain of quadriceps muscle, fascia and tendon
- S76.21: Strain of adductor muscle, fascia and tendon of thigh
- S76.81: Strain of other specified muscles, fascia and tendons at thigh level
- M75.20: Bicipital tendinitis, unspecified shoulder
- M75.30: Calcific tendinitis of unspecified shoulder
- M76.00: Gluteal tendinitis, unspecified hip
- M76.50: Patellar tendinitis, unspecified knee
- M76.70: Peroneal tendinitis, unspecified leg
- M71.9: Bursitis
- Stress injuries
- M84.3: Stress fracture
- M84.30: Stress fracture, unspecified site
- M84.31: Stress fracture, shoulder
- M84.34: Stress fracture, hand and fingers
- M84.37: Stress fracture, ankle, foot and toes
Sprains: A sprain is a partial tear to a ligament which is often caused by a twist. The areas of your body that’s most vulnerable to sprains are your ankles, knees, or wrists. If the sprain is severe, like if the ligament is completely torn, then surgical repair may be necessary.
Strain: A strain is an injury to a muscle and/or tendon caused by overuse or force, or stretching. It often can occur in your leg, your foot (typically the hamstring) or the back of your leg. General symptoms of a strain include pain, muscle spasms, weakness, swelling, inflammation, and cramping.
Tendonitis is a type of overuse injury to the tendons, the flexible band of tissue that connects the muscle to the bone. Areas commonly affected include the elbow, hand, wrist, shoulder, hip, knee, ankle, and foot.
Bursitis is caused due to inflammation of the bursa, which is a fluid-filled sac that provides a cushion between the bones and muscles or tendons. It can also be caused due to direct trauma to a joint. Body areas such as the shoulder, the elbow, the knee, the hip, the ankle, and foot are commonly affected by this condition.
Stress injuries are most often caused by overuse and increase in physical activity. The most common stress fracture is the small crack in a bone, commonly occurring in the weight-bearing bones of the lower extremities, including the legs, the hips, and feet. If the crack progresses further to a complete break, surgery may be required.
The treatments for soft-tissue injuries comprise Rest, Ice, Compression and elevation which is usually abbreviated as RICE. That protocol is very effective. But you can also use the No HARM Protocol which is HARM: Heat, Alcohol, Re-injury, and Massage. However, don’t use this method within the first 48–72 hours in order to speed up the recovery process.
So, don’t apply heat to the injured area as it can increase blood flow and swelling.
Alcohol can hinder the ability to feel if the injury is becoming more aggravated, as well as increasing blood flow and swelling.
Re-injury: Avoid any activities that could worsen the injury and cause further damage and massage. Even though massage in the injured area can promote blood flow and swelling, if it’s done too early it can cause more damage.
If severe pain persists after 24hours it is recommended that the patient consult an orthopedic professional who can make a diagnosis and implement a treatment plan so the patient can return to everyday activities. To make a full diagnosis, a professional may use nerve conduction studies to localize the nerve dysfunction.
I hope this helps, but always remember that documentation and a thorough knowledge of payer regulations and guidelines is critical to ensure accurate reimbursement for the procedures performed.
Thank you for listening!