2025 ICD-10-CM code S09.1
(Active) Effective Date: N/A Injury - Injuries to the head (S00-S09) Injury, poisoning and certain other consequences of external causes (S00-T88) Feed
Injury of muscle and tendon of head.
The ICD-10-CM code S09.1 does not have any applicable modifiers.
Medical necessity is established by the clinical documentation supporting the diagnosis of injury to the muscle and tendon of the head.This may include imaging evidence and physical exam findings.
Providers diagnose the condition on the basis of the patient’s medical history; physical examination to assess the degree of damage to the tissues; imaging techniques such as X–rays, CT scan, and MRI to rule out any fracture or whether the tear is partial or complete. Treatment options include medication such as analgesics, muscle relaxants, and nonsteroidal antiinflammatory drugs or NSAIDs; bracing or splinting to prevent movement and reduce pain or swelling; surgical management in case of severe injuries.
- Injury, poisoning and certain other consequences of external causes (S00-T88)
- Injuries to the head (S00-S09)
In simple words: Injury of muscle and tendon of head refers to tearing or pulling apart of muscles and tendons of the head. This can occur from a direct blow or sudden movement, leading to injury. Symptoms include pain, bruising, tenderness, swelling, stiffness, muscle spasms, weakness, and bleeding. Doctors diagnose this by medical history, physical examination, and imaging (X-rays, CT, MRI). Treatment may include pain medication, muscle relaxants, anti-inflammatory drugs, bracing or splinting, and sometimes surgery for severe injuries.
Injury of muscle and tendon of head.Code also any associated open wound (S01.-). Use secondary code(s) from Chapter 20 , External causes of morbidity, to indicate cause of injury. Use additional code to identify any retained foreign body, if applicable (Z18.-)
Example 1: A patient presents to the emergency room after being struck in the head with a baseball bat. Imaging reveals injury to the temporalis muscle and tendon., A patient falls and hits their head on the pavement. They experience pain and swelling in the occipital region, and examination reveals a strained trapezius muscle., A patient involved in a motor vehicle accident sustains whiplash, resulting in injury to the sternocleidomastoid muscle and tendon.
Documentation should include details of the injury mechanism, location and severity of the injury, associated symptoms, physical exam findings, and results of imaging studies.Any associated open wounds should also be documented.
** Excludes1: birth trauma (P10-P15), obstetric trauma (O70-O71)
- Specialties:Emergency Medicine, Trauma Surgery, Orthopedic Surgery, Neurology
- Place of Service:Emergency Room - Hospital, Inpatient Hospital, Office