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2025 ICD-10-CM code S66.2

Injury of the extensor muscle, fascia, and tendon of the thumb at the wrist and hand level.

Follow the official ICD-10-CM coding guidelines for injury coding, including the use of additional codes to specify the cause of injury, any associated open wounds, and retained foreign bodies.

Modifiers may be applicable depending on the circumstances of service.Consult the appropriate modifier guidelines for additional details.

Medical necessity is established based on the symptoms and physical examination findings consistent with an injury to the thumb extensor structures.Imaging may be medically necessary to rule out fractures and assess the extent of the soft tissue injury. Surgical repair is considered medically necessary if conservative management fails.

The clinical responsibility involves diagnosis through patient history and physical exam, potentially ordering imaging (X-rays, CT, MRI), determining the extent of the injury, and selecting appropriate treatment such as medication, bracing, activity modification, and possibly surgical intervention.

IMPORTANT:Use additional code to identify any retained foreign body, if applicable (Z18.-).Additional codes from Chapter 20 (External causes of morbidity) should be used to specify the cause of injury.Excludes: birth trauma (P10-P15), obstetric trauma (O70-O71), burns and corrosions (T20-T32), frostbite (T33-T34), insect bite or sting, venomous (T63.4), sprain of joints and ligaments of wrist and hand (S63.-).

In simple words: This code describes damage to the muscles, tissues, and tendons that straighten the thumb in the wrist and hand area, usually caused by an accident or injury.Symptoms might include pain, swelling, and difficulty moving the thumb. Treatment could include medication, splinting, and possibly surgery.

This ICD-10-CM code signifies injury to the extensor muscle, fascia, and tendon of the thumb located at the wrist and hand.The injury can manifest as pain, bruising, tenderness, swelling, stiffness, spasm, muscle weakness, and restricted movement. Diagnosis is typically made through patient history, physical examination, and imaging studies (X-rays, CT scans, MRI) to rule out fractures and assess the injury's extent. Treatment may involve analgesics, NSAIDs, activity modification, bracing, and potentially surgical repair.

Example 1: A patient presents after falling on their outstretched hand, experiencing pain and swelling in their thumb.Imaging reveals a partial tear of the extensor pollicis longus tendon.The physician diagnoses S66.2 and initiates conservative management with splinting and NSAIDs., A construction worker sustains a laceration to their thumb, involving damage to the extensor tendons.The physician performs surgical repair and codes the injury as S66.2, adding an additional code to describe the laceration., A patient is involved in a motor vehicle accident and presents with a complex injury to their hand, including a fracture and a tear of the extensor pollicis brevis muscle.The physician codes this as S66.2 for the muscle/tendon injury, and adds another code to reflect the fracture.

Detailed patient history including mechanism of injury, physical examination findings focusing on the thumb's range of motion, strength, and tenderness, and imaging reports (X-ray, CT, MRI) if performed.Operative notes if surgery is conducted.Progress notes documenting treatment and response.

** The severity of the injury can range from mild to severe, impacting treatment choices and coding considerations.Always ensure thorough documentation to support the chosen code.

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