Strain of muscle, fascia and tendon at neck level, subs

This code signifies a non-traumatic injury to the muscles, fascia, or tendons in the neck region, such as a "whiplash" injury or muscle pull, that is being treated during a follow-up visit. It indicates that the initial injury has already been assessed and treatment is ongoing or for a subsequent evaluation.

Apply this code for patients presenting for follow-up appointments related to a previously diagnosed neck strain. This includes physical therapy sessions, re-evaluation by a physician, or medication management for the healing injury. Documentation should clearly state "subsequent encounter" or indicate ongoing treatment for the strain.

• Ensure documentation specifies "subsequent encounter" or similar language to justify the "D" seventh character.
• Distinguish from initial encounters (S16.1XXA) and sequela (S16.1XXS) based on the patient's current phase of care.
• Always code the specific type of neck strain if further detail is provided (e.g., sternocleidomastoid strain), though S16.1 is for unspecified.