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ICD-10 Guide
DiagnosesTrapezius Muscle Spasm

Trapezius Muscle Spasm

ICD-10 Coding for Trapezius Muscle Spasm(M62.838)

PRIMARY SPECIALTYPhysical Therapy
COMPLEXITYHigh
LAST UPDATED09/15/2025
Sam Tuffun, PT, DPT
Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Trapezius Muscle Spasm?
Essential facts and insights about Trapezius Muscle Spasm

Key Clinical Considerations:

  • Localized pain and tenderness in the upper back and neck region
  • Restricted range of motion in the neck and shoulders
  • Muscle tightness or stiffness in the trapezius area

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history including onset, duration, and severity of symptoms
  • Physical examination findings including palpation results and range of motion assessments
  • Treatment plan and response to therapy

Coding Guidelines

Usage Guidelines & Examples

  • Follow specific guidelines for muscle spasm coding.
  • Common errors include misidentifying the muscle involved.

Code Exclusions

Important Exclusions

  • Cervical radiculopathy
  • Other muscle spasms not involving the trapezius

Related ICD-10 Codes

Primary Codes
M62.830
Muscle spasm of the trapezius muscle
Ancillary Codes
M54.2
S13.4
Differential Codes
M54.2
M79.1

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Physical Therapy

Specialty Applications

  • Adults and adolescents experiencing neck and shoulder pain
  • Outpatient physical therapy settings

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

  • Comprehensive clinical documentation
  • Accurate code selection based on clinical criteria
  • Proper exclusion considerations
  • Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

  • Ensure proper documentation for billing
  • Verify code specificity requirements
  • Check for any additional codes needed
  • Review payer-specific guidelines

Common Issues

  • Insufficient clinical documentation
  • Incorrect code selection
  • Missing supporting diagnoses
  • Timing and frequency documentation

Frequently Asked Questions

Documentation requirements?

Include detailed patient history, physical exam findings, and treatment response.

Billing considerations?

Ensure accurate coding and documentation to support medical necessity for therapy services.