Strain of unsp musc/tend at lower leg level, unsp leg, subs

This code signifies a muscle or tendon strain in the lower leg when the specific muscle or tendon involved is not documented. It is used for encounters following the initial treatment of the injury, indicating ongoing care or follow-up. The affected leg is also unspecified in the documentation.

This code is appropriate for follow-up visits where a patient is receiving continued treatment for a lower leg muscle or tendon strain, but the medical record does not specify which muscle/tendon or which leg. Examples include physical therapy sessions or re-evaluation appointments for a previously diagnosed, non-specific lower leg strain.

• Only use this code for subsequent encounters; an initial encounter would require a different seventh character.
• Avoid this code if the specific muscle, tendon, or leg is documented; seek a more precise code.
• Query the provider if the documentation is unclear regarding the specific muscle/tendon, leg, or encounter type.