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S86.111A
ICD-10-CM
Right Calf Strain

Find information on right calf strain diagnosis, including clinical documentation, medical coding, and healthcare resources. Learn about calf muscle strain ICD-10 codes, right calf pain differential diagnosis, and treatment options. Explore resources for accurate medical coding for right calf strain and best practices for documenting calf muscle injuries in clinical settings. This comprehensive guide covers right leg muscle strain symptoms, calf strain grades, and related muscle tear information for healthcare professionals and patients.

Also known as

Right Posterior Calf Muscle Strain
Right Soleus Strain

Diagnosis Snapshot

Key Facts
  • Definition : Tear in right calf muscle (gastrocnemius or soleus)
  • Clinical Signs : Sudden pain, swelling, bruising, tightness, limited range of motion in ankle
  • Common Settings : Sports injuries, falls, overuse, sudden changes in activity

Related ICD-10 Code Ranges

Complete code families applicable to AAPC S86.111A Coding
S86.1-

Injury of muscle, fascia and tendon at lower leg level

Covers specific lower leg muscle/tendon injuries.

S86.-

Injury of muscle, fascia and tendon of lower leg

Includes broader lower leg muscle/tendon injuries.

S76.-

Injury of muscle, fascia and tendon at ankle and foot level

Includes injuries to the ankle/foot muscles/tendons.

M79.1-

Myalgia

Covers muscle pain, which may be associated with a strain.

Code-Specific Guidance

Decision Tree for

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

Traumatic strain of right calf?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right calf strain
Right calf muscle tear
Right Achilles tendinitis

Documentation Best Practices

Documentation Checklist
  • Calf strain laterality (right)
  • Detailed injury mechanism
  • Physical exam: Palpation, ROM
  • Pain level/severity documentation
  • ICD-10 code: S86.111A (example)

Mitigation Tips

Best Practices
  • RICE therapy (rest, ice, compression, elevation) for acute calf strain management. ICD-10: S86.1, S23.409A
  • Document pain onset, location, mechanism. CDI: Muscle tear vs. sprain. CPT: 99213-99215
  • Assess ROM, palpate for tenderness, edema. HPI must support Dx for compliance. ICD-10: M79.101
  • Consider imaging (ultrasound/MRI) for severe strains to r/o other injuries. CPT: 73721, 73722
  • Prescribe NSAIDs, physical therapy referral. Document treatment plan for compliance. CPT: 97110

Clinical Decision Support

Checklist
  • 1. Sudden calf pain during exertion? (ICD-10 S53.401)
  • 2. Posterior calf tenderness/edema? Document palpation findings.
  • 3. Thompson test negative rules out Achilles rupture. (SNOMED CT 307712004)
  • 4. Evaluate ROM and strength. Document severity (mild, moderate, severe).

Reimbursement and Quality Metrics

Impact Summary
  • Right Calf Strain reimbursement impacted by accurate ICD-10 S86.1xx coding for laterality and severity.
  • Quality metrics: Calf strain recovery time, pain management effectiveness, and return to activity rate.
  • Coding accuracy crucial for proper reimbursement under musculoskeletal injury DRGs.
  • Hospital reporting on calf strain diagnoses impacts resource allocation and quality improvement initiatives.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Code calf strain S86.1, specify laterality
  • Document injury mechanism, severity
  • Consider M79.1 for calf pain NOS
  • Ruling out DVT crucial for S86.1
  • Document ROM, tenderness location

Documentation Templates

Patient presents with complaints of right calf pain, consistent with a right calf strain or pulled calf muscle.  Onset of pain occurred [Date of Onset] while [Mechanism of Injury - e.g., running, jumping, sudden change in direction].  Patient reports [Character of pain - e.g., sharp, dull, aching, throbbing] pain localized to the [Specific location of pain - e.g., medial head of gastrocnemius, lateral head of gastrocnemius, soleus muscle] area of the right calf.  Pain is aggravated by [Aggravating factors - e.g., weight bearing, plantarflexion, dorsiflexion] and alleviated by [Alleviating factors - e.g., rest, ice, elevation].  Patient denies any numbness, tingling, or coolness in the foot.  Physical examination reveals [Objective findings - e.g., tenderness to palpation, edema, ecchymosis, palpable defect] in the right calf.  Range of motion of the right ankle is [Range of motion - e.g., limited, full, with pain on plantarflexion or dorsiflexion].  Neurovascular exam of the right lower extremity is intact.  Diagnosis of right calf muscle strain is made, likely grade [Grade of strain - e.g., I, II, III] based on clinical presentation.  Differential diagnoses include Achilles tendon rupture, deep vein thrombosis, and muscle contusion.  Treatment plan includes RICE therapy (rest, ice, compression, elevation), NSAIDs for pain management, and gradual return to activity as tolerated.  Patient advised to follow up in [Duration] for reevaluation.  Instructions provided on stretching and strengthening exercises for calf muscle rehabilitation.  ICD-10 code S86.111A assigned for right calf muscle strain.