ICD-10 Coding for Spasm(M62.830, R25.2)
Complete ICD-10-CM coding and documentation guide for Spasm. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Spasm
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| M62.830 | Muscle spasm of back | Use when documenting a muscle spasm specifically in the back without neurological deficits. |
|
| R25.2 | Cramp and spasm | Use when the spasm is generalized or unspecified. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for muscle spasm of the back
Essential facts and insights about Spasm
Primary ICD-10-CM Codes for spasm
Decision Criteria
clinical Criteria
- Presence of palpable muscle rigidity
documentation Criteria
- Documentation of sudden onset of pain
Applicable To
- Back muscle spasm
Excludes
- Radiculopathy (M54.1)
Clinical Validation Requirements
- Sudden onset of pain
- Palpable muscle rigidity
- Absence of neurological deficits
Code-Specific Risks
- Risk of under-documentation if neurological deficits are present.
Coding Notes
- Ensure documentation specifies the absence of neurological deficits.
R25.2 - Cramp and spasm
Use when the spasm is generalized or unspecified.
Applicable To
- Unspecified spasm
Excludes
- Specific muscle spasms (M62.8)
Clinical Validation Requirements
- Generalized spasm without specific site documentation
Coding Notes
Ensure no specific site is documented when using this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Activity, weightlifting
Y93.22Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Spasm to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code M62.830.
Impact
Clinical: Leads to inaccurate clinical records., Regulatory: May result in audit issues., Financial: Potential for incorrect billing.
Mitigation Strategy
Review documentation for specificity., Use coding guidelines to select appropriate codes.
Impact
Reimbursement: May lead to incorrect reimbursement rates., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Use M62.830 for back muscle spasms.
Impact
Risk of audits due to non-specific documentation of spasms.
Mitigation Strategy
Ensure detailed documentation of spasm characteristics.
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 Spasm, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Spasm
Use these documentation templates to ensure complete and accurate documentation for Spasm. These templates include all required elements for proper coding and billing.
Acute back spasm post-exercise
Specialty: OrthopedicsRequired Elements
- Onset and duration of spasm
- Location and severity
- ROM impact
- Palpation findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Spasm? Ask your questions below.