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

This code signifies a long-term or late effect resulting from a previous injury to the muscles, fascia, or tendons in the neck region. It indicates that the patient is experiencing residual symptoms or complications directly attributable to a past neck strain, rather than an acute injury.

Apply this code when documentation clearly states a patient's current neck muscle, fascia, or tendon issues are a direct consequence of a prior strain, and the acute phase of the original injury has passed. This is appropriate for conditions like chronic neck pain, stiffness, or limited range of motion persisting after an initial neck strain. Documentation should specify the sequela and its link to the previous strain.

• Always sequence the sequela code (S16.1XXS) after the code describing the specific residual condition (e.g., chronic pain, stiffness).
• Ensure the medical record explicitly links the current neck symptoms to a past strain, not an ongoing acute injury.
• Do not use this code for acute or current neck strains; those require codes from the initial or subsequent encounter categories.