S39.012D Strain of muscle, fascia and tendon of lower back, subsequent encounter

ICD10CM code

#### Name of the Condition
- Strain of Muscle, Fascia, and Tendon of Lower Back
- Medical Term: S39.012D

#### Summary
- A strain of the muscle, fascia, and tendon of the lower back is an injury that occurs when these tissues are overstretched or torn, leading to pain and discomfort. This entry, marked as "subsequent encounter," refers to follow-up visits after the initial treatment.

#### Causes
- Strains can be caused by heavy lifting, sudden movements, overstretching, or direct trauma to the lower back.

#### Risk Factors
- Engaging in sports or activities involving heavy lifting.
- Poor posture or improper conditioning of back muscles.
- Previous history of similar injuries.
- Age-related degeneration of tissues increasing vulnerability.

#### Symptoms
- Pain and soreness in the lower back.
- Limited range of motion or stiffness.
- Swelling or bruising over the affected area.

#### Diagnosis
- Physical examination to assess range of motion and tenderness.
- Imaging tests, such as MRI or X-ray, may be used to rule out other conditions.

#### Treatment Options
- Rest and avoidance of activities that may exacerbate the pain.
- Application of ice packs to reduce swelling.
- Physical therapy to strengthen back muscles.
- Pain relief medications like NSAIDs for management of symptoms.
- Severe cases may require corticosteroid injections or surgery.

#### Prognosis and Follow-Up
- Most individuals recover with proper rest and rehabilitation.
- Follow-up appointments are crucial to monitor the healing process and adjust treatment plans accordingly.
- Long-term outlook is generally positive if the condition is managed correctly.

#### Complications
- Chronic back pain if not treated properly.
- Risk of recurrent strains or injuries if preventative measures are not taken.

#### Lifestyle & Prevention
- Engaging in exercises to strengthen core and back muscles.
- Practicing good posture and using ergonomic furniture.
- Gradual warming up before physical activities to prevent sudden injuries.

#### When to Seek Professional Help
- Worsening pain or symptoms despite self-care measures.
- Numbness or weakness in legs which could indicate a more serious condition.
- Persistent symptoms affecting daily activities.

#### Additional Resources
- American Chiropractic Association: [www.acatoday.org](https://www.acatoday.org)
- Spine Health: [www.spinehealth.com](https://www.spine-health.com)

#### Tips for Medical Coders
- Ensure correct usage of subsequent encounter code to indicate follow-up care.
- Verify that coding reflects the current state of treatment planning and progress.
- Avoid using incorrect codes for initial encounters when the visit is for continued care.

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