Strain of muscle and tendon of head, subsequent encounter

This code signifies a non-traumatic injury to the muscles or tendons of the head, such as those involved in mastication or neck movement, that is being treated after the initial encounter. It indicates an overuse injury, sprain, or tear of these soft tissues. The injury is not due to an external force or impact.

Use this code for follow-up visits, rehabilitation, or ongoing management of a muscle or tendon strain in the head region. Documentation should clearly state "strain" or "sprain" of a head muscle/tendon and specify that it is a subsequent encounter for treatment. This code is appropriate when the patient is receiving active treatment for the injury, such as physical therapy, medication management, or re-evaluation.

• Ensure documentation specifies "subsequent encounter" for ongoing treatment, not initial care or sequela.
• Differentiate from traumatic injuries to the head muscles/tendons, which would fall under different S09 subcategories.
• Confirm the injury is a "strain" or "sprain" and not a contusion, laceration, or other type of head injury.