ICD-10 Coding for Cervical Paraspinal Muscle Spasm(M62.838)
Complete ICD-10-CM coding and documentation guide for Cervical Paraspinal Muscle Spasm. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cervical Paraspinal Muscle Spasm
M62.830-M62.839Primary Range
Muscle spasm codes for various sites
This range includes codes for muscle spasms at different anatomical sites, including the neck and back.
Key Information: ICD-10 code for cervical paraspinal muscle spasm
Essential facts and insights about Cervical Paraspinal Muscle Spasm
Primary ICD-10-CM Code for cervical paraspinal muscle spasm
Decision Criteria
clinical Criteria
- Presence of muscle spasm in cervical paraspinal region confirmed by physical exam or imaging.
documentation Criteria
- Detailed documentation of spasm location and severity.
Applicable To
- Cervical paraspinal muscle spasm
Excludes
- Muscle spasm of unspecified site (M62.839)
Clinical Validation Requirements
- Palpable taut bands in cervical paraspinal muscles
- EMG-confirmed hypertonicity localized to C4-C7 paraspinals
- MRI showing edema in cervical paraspinals
Code-Specific Risks
- Misclassification if the specific site is not documented.
Coding Notes
- Ensure documentation specifies 'cervical paraspinal muscles' to support M62.838.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Chemodenervation of neck muscles
64616Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Cervical Paraspinal Muscle Spasm to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M62.838.
Impact
Clinical: Inaccurate clinical records., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Always document the side affected (left, right, or bilateral)., Use templates to ensure completeness.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Specify exact muscle group: 'Cervical paraspinals' → M62.838
Impact
Using M62.839 without specifying the site can lead to audits.
Mitigation Strategy
Ensure documentation specifies the exact site of the spasm.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Cervical Paraspinal Muscle Spasm, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cervical Paraspinal Muscle Spasm
Use these documentation templates to ensure complete and accurate documentation for Cervical Paraspinal Muscle Spasm. These templates include all required elements for proper coding and billing.
Neurology Progress Note
Specialty: NeurologyRequired Elements
- Subjective: Patient's description of symptoms.
- Objective: Physical exam findings.
- Assessment: Diagnosis with ICD-10 code.
- Plan: Treatment plan including procedures.
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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