Strain of right quadriceps muscle, fascia and tendon, subs

This code signifies a non-traumatic injury to the right quadriceps muscle, its surrounding fascia, or its tendon, characterized by overstretching or tearing of the fibers. It indicates that the patient is receiving follow-up care for an injury that has already been initially treated.

Apply this code when a patient presents for ongoing treatment, such as physical therapy, medication management, or follow-up evaluations, for a previously diagnosed strain of the right quadriceps. This includes scenarios where the patient is recovering from the initial injury and is no longer in the acute phase of care.

• Ensure documentation specifies "right" quadriceps and clearly indicates a "subsequent encounter" for the injury.
• Verify the encounter is not for the initial treatment of the strain; if it is, a code from the "A" (initial encounter) category would be appropriate.
• Look for documentation of physical therapy, rehabilitation, or follow-up appointments related to the strain.