Find comprehensive information on hamstring tear diagnosis, including clinical documentation, medical coding (ICD-10, S-codes), and healthcare resources. Learn about hamstring strain grades, symptoms, physical exam findings, and differential diagnoses. This resource provides guidance for accurate medical coding and documentation of hamstring injuries for physicians, clinicians, and medical coders. Explore details on hamstring tear treatment, prognosis, and return to activity guidelines.
Also known as
Injury of hamstring muscle
Covers tears and other injuries to the hamstring muscles.
Injury of muscle, fascia and tendon at lower leg level
Includes injuries to muscles, fascia, and tendons in the lower leg area.
Injury of muscle, fascia and tendon at thigh level
Includes injuries to muscles, fascia, and tendons in the thigh area.
Follow this step-by-step guide to choose the correct ICD-10 code.
Traumatic hamstring tear?
Yes
Which leg?
No
Strain or other non-traumatic tear?
When to use each related code
Description |
---|
Hamstring tear |
Hamstring strain |
Sciatica |
Missing or incorrect laterality (right, left, bilateral) for hamstring tear diagnoses can lead to claim rejections and inaccurate data.
Coding a hamstring tear without specifying complete/partial or grade (1, 2, 3) impacts reimbursement and quality reporting.
Vague documentation lacking clear diagnostic confirmation of a hamstring tear via physical exam or imaging can cause coding errors.
Patient presents with complaints consistent with hamstring tear, possibly sustained during [activity causing injury]. Onset of symptoms occurred [timeframe] ago. Patient reports [sharp, pulling, tearing] pain in the posterior thigh, localized to [proximal, mid, distal] hamstring musculature. Pain is exacerbated by [activities that worsen pain, e.g., knee flexion, hip extension, stretching, weight-bearing]. Patient may also report symptoms such as [popping sensation, bruising, swelling, tenderness to palpation, muscle spasm, weakness, difficulty walking]. Physical examination reveals [positive findings, e.g., palpable defect, ecchymosis, limited range of motion, pain with resisted knee flexion or hip extension, positive Straight Leg Raise test, tenderness to palpation]. Differential diagnosis includes hamstring strain, muscle contusion, sciatica, avulsion fracture. Severity of hamstring tear is suspected to be [grade 1, grade 2, grade 3] based on clinical presentation. Imaging studies, such as ultrasound or MRI, may be ordered to confirm diagnosis and assess the extent of the tear. Initial treatment plan includes RICE protocol (rest, ice, compression, elevation), pain management with NSAIDs or other analgesics as indicated, and physical therapy referral. Patient education provided on activity modification, stretching, and strengthening exercises. Follow-up scheduled in [timeframe] to reassess symptoms and adjust treatment plan as needed. Prognosis for recovery depends on the severity of the tear and adherence to treatment recommendations. ICD-10 code: [appropriate ICD-10 code, e.g., S76.1xxA, S76.1xxD, S76.1xxS].