ICD-10-CM Code for Bilateral Groin Strain
The ICD-10-CM code for bilateral adductor (groin) strain is S76.213, where the final digit "3" specifically designates bilateral involvement.
Code Structure and Laterality
- The ICD-10-CM system uses a standardized laterality designation in the final character position: right = 1, left = 2, and bilateral = 3 1, 2, 3
- For a bilateral groin strain, you must use the code that ends in "3" to indicate both sides are affected 1, 4
- The S76.2 category specifically covers strain of adductor muscle, fascia and tendon of thigh, which encompasses groin strains 1
Coding Specificity Requirements
- Always code to the highest level of specificity available in your documentation 2, 5
- The complete code S76.213 requires all six characters, with the final "3" being mandatory to indicate bilateral involvement 1
- Unspecified codes should only be used when documentation does not support a more specific diagnosis 2, 5
Common Coding Pitfalls
- Do not assign separate codes for right (S76.211) and left (S76.212) when the condition is truly bilateral—use the single bilateral code S76.213 instead 1
- Ensure your clinical documentation explicitly states "bilateral" to support use of the "3" designation 6, 5
- The adductor muscle group strain is anatomically distinct from hip flexor or other thigh muscle strains, which have different code categories 1
Clinical Documentation Support
- Document the specific mechanism of injury and functional limitations to support medical necessity 7
- Note that adductor muscle strain involves the muscle group responsible for leg adduction and gripping movements 1
- Include whether this is an initial encounter, subsequent encounter, or sequela, as this requires an additional 7th character extension 1