Find information on Right Wrist Strain diagnosis, including clinical documentation tips, ICD-10 codes (S63.5xx), medical coding guidelines, and healthcare resources. Learn about symptoms, treatment, and proper documentation for right wrist sprain, strain, and pain. Explore resources for accurate medical coding and billing related to right wrist injuries.
Also known as
Dislocations, sprains, and strains of wrist
Covers injuries to the wrist including sprains and strains.
Myalgia
Pain in the muscles, which can be associated with wrist strain.
Pain in right wrist
Specifies pain localized to the right wrist.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is there a complete tear of a ligament in the right wrist?
Yes
Code a right wrist sprain with a 7th character for subsequent encounter (S63.51XD) or sequela (S63.51XS) as appropriate. Add additional codes for the tear of the specific ligament.
No
Is it an initial encounter?
When to use each related code
Description |
---|
Right Wrist Strain |
Right Wrist Sprain |
Right Wrist Tendinitis |
Coding right wrist strain without specifying laterality (right) can lead to claim rejections. Use specific ICD-10 codes for accuracy.
Incorrectly coding a sprain as a strain or vice versa impacts data integrity and reimbursement. CDI ensures proper documentation for accurate coding.
Insufficient documentation of the cause, severity, and treatment of the right wrist strain leads to coding errors and compliance risks. Thorough documentation is crucial.
Patient presents with complaints of right wrist pain consistent with a right wrist strain. Onset of pain occurred [Date of onset] while [Mechanism of injury - e.g., lifting a heavy object, falling on an outstretched hand]. Patient denies any prior history of right wrist injury or surgery. Pain is described as [Character of pain - e.g., sharp, aching, throbbing] and located [Location of pain - e.g., on the lateral aspect, dorsum, volar aspect] of the wrist. Patient reports [Severity of pain - e.g., mild, moderate, severe] pain, exacerbated by [Exacerbating factors - e.g., movement, palpation, weight-bearing]. Pain is alleviated by [Alleviating factors - e.g., rest, ice, elevation]. Physical examination reveals [Objective findings - e.g., tenderness to palpation over the [Specific anatomical location - e.g., scaphoid, lunate, anatomical snuffbox], mild swelling, ecchymosis, limited range of motion]. No crepitus or deformity noted. Neurovascular exam intact with normal sensation and capillary refill in the digits. Strength testing is [Strength - e.g., 5/5, 4/5] in the right hand and wrist. Differential diagnosis includes wrist sprain, fracture, tendonitis, and carpal tunnel syndrome. Assessment: Right wrist strain. Plan: Conservative management with RICE (rest, ice, compression, elevation). Patient instructed to avoid strenuous activities involving the right wrist. Over-the-counter pain relievers such as ibuprofen or naproxen recommended for pain management. Follow-up scheduled in [Duration - e.g., one week, two weeks] to assess response to treatment. Referral to physical therapy may be considered if symptoms persist. ICD-10 code: S63.501A - Sprain of unspecified ligament of right wrist, initial encounter.