ICD-10 Guide

R25.2

Cramp and spasm

BILLABLE STATUSYes

IMPLEMENTATION DATEOctober 1, 2015

LAST UPDATED09/11/2025

Code Description

ICD-10 R25.2 is a billable code used to indicate a diagnosis of cramp and spasm.

Key Diagnostic Point:

Cramp and spasm (ICD-10 code R25.2) refers to involuntary muscle contractions that can cause pain and discomfort. These symptoms may occur in various muscle groups and can be transient or chronic. Cramping can be associated with dehydration, electrolyte imbalances, overexertion, or underlying medical conditions such as peripheral artery disease or neurological disorders. Spasms may also arise from muscle fatigue, stress, or certain medications. Clinically, patients may present with sudden onset of muscle tightness, pain, and restricted movement. The diagnosis often involves a thorough patient history, physical examination, and may include laboratory tests to assess electrolyte levels and other potential underlying causes. Understanding the context of these symptoms is crucial for accurate diagnosis and treatment, as they can significantly impact a patient's quality of life.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

Variety of potential underlying causes
Need for thorough patient history and examination
Differentiation from other similar symptoms
Potential for chronic vs. acute presentation

Audit Risk Factors

Inadequate documentation of symptoms
Failure to specify the muscle group affected
Lack of correlation between symptoms and diagnosis
Misuse of related codes leading to upcoding or downcoding

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed patient history, including onset, duration, and frequency of cramps and spasms, as well as any associated symptoms.

Common Clinical Scenarios

Patients presenting with muscle cramps due to dehydration or electrolyte imbalances, often seen in chronic illness management.

Billing Considerations

Consideration of comorbidities that may contribute to muscle cramps, such as diabetes or renal disease.

Emergency Medicine

Documentation Requirements

Acute presentation documentation, including vital signs, immediate interventions, and response to treatment.

Common Clinical Scenarios

Patients presenting with acute muscle spasms following strenuous activity or trauma.

Billing Considerations

Rapid assessment of potential underlying causes, including ruling out serious conditions like compartment syndrome.

Coding Guidelines

Inclusion Criteria

Use R25.2 When

Follow official ICD
10 coding guidelines, ensuring that the code is used only when cramps and spasms are not classified elsewhere
Document the clinical context and any relevant findings

Exclusion Criteria

Do NOT use R25.2 When

No specific exclusions found.

Related CPT Codes

99213CPT Code

Established patient office visit, Level 3

Clinical Scenario

Used when evaluating a patient with recurrent muscle cramps in an outpatient setting.

Documentation Requirements

Document the history of present illness, review of systems, and any physical exam findings.

Specialty Considerations

Internal medicine may require additional documentation of chronic conditions contributing to symptoms.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of symptoms like cramps and spasms, improving the ability to capture the complexity of these conditions and their underlying causes.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of symptoms like cramps and spasms, improving the ability to capture the complexity of these conditions and their underlying causes.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of symptoms like cramps and spasms, improving the ability to capture the complexity of these conditions and their underlying causes.

Resources

Clinical References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

•
ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

When should I use R25.2?

Use R25.2 when documenting muscle cramps and spasms that are not classified elsewhere, ensuring that the clinical context is well-documented.

ICD-10 R25.2 is a billable code used to indicate a diagnosis of cramp and spasm.