What is the ICD-10 (International Classification of Diseases, 10th Revision) diagnosis code for a patient presenting with muscular spasm?

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ICD-10 Diagnosis Code for Muscular Spasm

The ICD-10-CM code for muscular spasm is M62.838 (other muscle spasm) for most clinical presentations, though the specific anatomic location may require more precise coding such as M62.83 for muscle spasm of unspecified site.

Primary Coding Approach

The ICD-10-CM system provides more anatomically specific coding options compared to ICD-9-CM, allowing for better documentation of the exact location and nature of muscle spasms 1, 2.

Standard Muscle Spasm Codes

  • M62.838 is the most commonly used code for "other muscle spasm" when the spasm doesn't fit into more specific categories 2
  • M62.83 can be used for muscle spasm of unspecified site when location is not documented 3
  • The M62.8 series specifically addresses muscle disorders including spasms, distinguishing them from other musculoskeletal conditions 2

Context-Specific Coding Considerations

When Spasm is Secondary to Neurologic Disease

If the muscular spasm results from upper motor neuron lesions (stroke, multiple sclerosis, spinal cord injury), you must code the underlying neurologic condition first, then add the muscle spasm code as a secondary diagnosis 4. For example:

  • Primary code: The neurologic condition (e.g., I63.9 for cerebral infarction)
  • Secondary code: M62.838 for the resulting muscle spasm

When Spasm Involves Specific Anatomic Regions

For certain locations, more specific codes exist 5:

  • Cricopharyngeal spasm causing dysphagia has distinct coding under esophageal disorders 5
  • Coronary artery spasm requires cardiovascular system codes, not musculoskeletal codes 5
  • Calf muscle cramps would still use M62.838 but documentation should specify the lower extremity involvement 6

Common Coding Pitfalls to Avoid

Do not confuse muscle spasm with increased muscle tone from spasticity - these are distinct entities requiring different ICD-10 codes 4. Spasticity from upper motor neuron lesions has separate coding under neurologic conditions.

Avoid using non-specific pain codes (like R52.2 "other chronic pain") when muscle spasm is the documented diagnosis, as this provides less clinically useful information 2. The ICD-10-CM system's strength is its specificity compared to ICD-10's tendency toward vague "other" categories 2.

Document the anatomic location precisely in the medical record to support the most specific code selection, as ICD-10-CM emphasizes anatomic detail over ICD-9-CM 1, 3.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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