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S13.4xxA
ICD-10-CM
Neck Sprain

Find information on neck sprain diagnosis, including clinical documentation, ICD-10 codes (S13.4xxA, S13.4xxD), medical coding guidelines, and treatment options. Learn about whiplash-associated disorders, cervical strain, acute neck pain, and related symptoms for accurate healthcare record keeping. This resource helps medical professionals ensure proper documentation and coding for neck sprains.

Also known as

Cervical Sprain
Whiplash

Diagnosis Snapshot

Key Facts
  • Definition : Stretching or tearing of neck ligaments, causing pain and stiffness.
  • Clinical Signs : Neck pain, stiffness, muscle spasms, headaches, limited range of motion.
  • Common Settings : Sudden movements, falls, whiplash, sports injuries, poor posture.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S13.4xxA Coding
S13.4-

Sprain of cervical spine

Sprains of neck ligaments causing pain and limited motion.

S13.-

Dislocation, sprain, and strain of joints and ligaments of neck

Includes various neck injuries like dislocations, sprains, and strains.

S00-S09

Injuries to the head

While less specific, neck sprains can be associated with head injuries.

M54.-

Dorsalgia

Neck sprain can cause back pain, sometimes classified as dorsalgia.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the neck sprain traumatic?

  • Yes

    Current injury?

  • No

    Is there inflammation?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Neck sprain
Whiplash injury
Cervical strain

Documentation Best Practices

Documentation Checklist
  • Neck pain onset, date, and time
  • Mechanism of injury details
  • Symptoms: limited ROM, stiffness
  • Physical exam: tenderness, spasm
  • Imaging results if performed

Coding and Audit Risks

Common Risks
  • Unspecified Sprain

    Coding neck sprain as unspecified (S13.9) when more specific documentation like laterality or degree is available, leading to inaccurate severity capture.

  • Whiplash Miscoding

    Incorrectly coding whiplash (S13.4) as a simple neck sprain or vice versa, potentially impacting reimbursement and quality metrics.

  • Documentation Deficiency

    Lack of specific documentation regarding the cause, location, and severity of the neck sprain hinders accurate code assignment and audit defense.

Mitigation Tips

Best Practices
  • Document initial & follow-up MSK exam, ICD-10 S13.4xx, CPT 99202-99215
  • Correlate subjective complaints to objective findings for accurate coding compliance
  • Query MD for laterality, specific muscle involvement S16.1xx, S16.2xx (CDI)
  • Assess NEXUS criteria/Canadian C-Spine rules for imaging (medical necessity)
  • Document pain management, PT referrals for improved patient outcomes, coding E/M

Clinical Decision Support

Checklist
  • Confirm trauma mechanism: sudden neck movement
  • Rule out red flags: fever, myelopathy, fracture
  • Palpate for tenderness, spasm, limited ROM
  • Evaluate neurologic status: strength, reflexes
  • Document detailed history and physical exam findings

Reimbursement and Quality Metrics

Impact Summary
  • Neck Sprain reimbursement hinges on accurate ICD-10 S13.4xx coding, impacting claim denial rates.
  • Proper documentation of neck sprain severity (e.g., whiplash, strain) affects E/M code selection and payment.
  • Missed neck sprain diagnoses impact hospital quality reporting on trauma and musculoskeletal care.
  • Accurate neck sprain coding improves data integrity for population health management and resource allocation.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • ICD-10 S13.4xx for neck sprain
  • Specify laterality: right, left, bilateral
  • Document mechanism of injury
  • Include pain severity and ROM
  • Consider 7th character for initial/subsequent

Documentation Templates

Patient presents with complaints of neck pain and stiffness, consistent with a neck sprain or whiplash injury.  Onset of symptoms occurred following [Mechanism of injury - e.g., motor vehicle accident, fall, sudden movement].  Patient reports [Severity - e.g., mild, moderate, severe] pain localized to the [Location - e.g., cervical spine, paraspinal muscles, upper back] with associated [Symptoms - e.g., muscle spasms, limited range of motion, headaches, radiating pain to shoulders or arms].  Pain is aggravated by [Aggravating factors - e.g., movement, palpation, prolonged sitting] and relieved by [Relieving factors - e.g., rest, ice, over-the-counter pain medication].  Physical examination reveals [Objective findings - e.g., tenderness to palpation, muscle spasm, decreased range of motion in flexion, extension, lateral rotation, lateral bending].  Neurological examination is [Neurological findings - e.g., intact, with no evidence of radiculopathy or myelopathy].  Differential diagnoses include cervical strain, facet joint syndrome, disc herniation.  Impression is neck sprain (ICD-10 code S33.6).  Treatment plan includes [Treatment - e.g., rest, ice, heat therapy, NSAIDs, muscle relaxants, physical therapy, cervical collar].  Patient advised to follow up in [Follow-up duration - e.g., one week, two weeks] to assess response to treatment.  Patient education provided regarding proper posture, ergonomics, and activity modification.  Prognosis is good with conservative management.
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