Strain of musc/fasc/tend long head of biceps, unsp arm, subs

This code signifies a non-traumatic injury to the long head of the biceps muscle, its surrounding fascia, or its tendon, that is not specified to a particular arm. It indicates a muscle strain, which is a stretching or tearing of muscle fibers, and is used for follow-up care after the initial injury has been addressed.

Apply this code when documenting a patient's visit for ongoing treatment, rehabilitation, or follow-up after the initial diagnosis and management of a biceps strain. This would include scenarios like physical therapy sessions, re-evaluation appointments, or medication refills for a previously diagnosed strain of the long head of the biceps, where the affected arm was not specified in the documentation.

• Ensure documentation clearly states "subsequent encounter" or similar language indicating ongoing care.
• Verify the specific muscle involved is the "long head of biceps" and not another muscle in the arm.
• Only use this code when the laterality (left or right arm) is not documented by the provider.