ICD-10 Coding for Neck Spasm(M62.838)
Complete ICD-10-CM coding and documentation guide for Neck Spasm. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Neck Spasm
M62.830-M62.838Primary Range
Muscle spasm codes, including specific regions
This range includes codes for muscle spasms in various body regions, with M62.838 specifically for neck muscle spasms.
Codes for cervicalgia and cervical radiculopathy
These codes are used when neck pain or radiculopathy is present, but not primarily for muscle spasms.
Sprain of cervical ligaments
Used when neck spasms are associated with trauma leading to ligament sprain.
Key Information: ICD-10 code for neck spasm
Essential facts and insights about Neck Spasm
Primary ICD-10-CM Code for neck spasm
Decision Criteria
clinical Criteria
- Presence of palpable muscle spasm and restricted ROM
coding Criteria
- Absence of trauma or radiculopathy
documentation Criteria
- Detailed description of muscle involvement and functional impact
Applicable To
- Neck muscle spasm
Excludes
- Spasmodic torticollis (G24.3)
Clinical Validation Requirements
- Palpable muscle tightness in the neck region
- Restricted cervical range of motion (ROM)
- Absence of neurological deficits
Code-Specific Risks
- Incorrectly coding as cervicalgia (M54.2) when spasm is the primary issue.
Coding Notes
- Ensure documentation specifies muscle spasm as the primary issue, with detailed physical exam findings.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Cervical radiculopathy
M54.12Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Neck 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: May lead to inappropriate treatment plans., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials or reduced reimbursement.
Mitigation Strategy
Train staff on detailed documentation practices., Use templates to ensure all required elements are captured.
Impact
Reimbursement: Potential underpayment due to incorrect coding., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Document the presence of muscle spasm explicitly and use M62.838.
Impact
Coding neck spasms as general neck pain without specifying spasm.
Mitigation Strategy
Regular audits and coder training on specific documentation requirements.
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 Neck Spasm, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Neck Spasm
Use these documentation templates to ensure complete and accurate documentation for Neck Spasm. These templates include all required elements for proper coding and billing.
Acute Neck Spasm
Specialty: OrthopedicsRequired Elements
- Location of spasm
- Severity and impact on function
- Duration and onset
- Associated symptoms
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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