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v1.0.0
ICD-10 Guide
DiagnosesLower Back Muscle Spasm

Lower Back Muscle Spasm

ICD-10 Coding for Lower Back Muscle Spasm(M62.830, M54.5, S39.012)

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

Diagnosis Overview

What is Lower Back Muscle Spasm?
Essential facts and insights about Lower Back Muscle Spasm

Key Clinical Considerations:

  • Localized pain in the lower back
  • Muscle tightness or stiffness
  • Inability to maintain normal posture
  • Pain exacerbated by movement or palpation
  • Possible radiation of pain to the buttocks or thighs

Clinical Information

Clinical Criteria & Documentation Requirements

  • Patient history including onset and duration of symptoms
  • Description of pain characteristics (e.g., sharp, dull)
  • Results of physical examination including range of motion
  • Assessment of functional limitations
  • Treatment plan and response to therapy

Coding Guidelines

Usage Guidelines & Examples

  • Follow usage guidelines to avoid incorrect coding.
  • Common errors include misidentifying the primary diagnosis or failing to document functional limitations.

Code Exclusions

Important Exclusions

  • Fractures or dislocations of the spine
  • Conditions like herniated discs or spinal stenosis
  • Alternative codes for specific underlying conditions

Related ICD-10 Codes

Primary Codes
M62.830
Muscle spasm of lower back
Ancillary Codes
M54.5
Differential Codes
S39.012

Related CPT Codes

CPT codes will be available in a future update.

Specialty Focus

Primary Specialty

Physical Therapy

Specialty Applications

  • Adults experiencing acute or chronic lower back 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

What are the documentation requirements?

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

What are the billing considerations?

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