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Back Pain with Muscle Spasm


Question

When a patient is given a diagnosis of back pain with muscle spasm should the muscle spasm also be coded? If so, would you code it as 728.85 Spasm of Muscle or 724.8 Other symptoms referable to back?

Answer

It would appear that both the back pain and muscle spasm could be coded.  If the diagnosis is listed as back pain with muscle spasm, the muscle spasm would also be in the back.  724.8 would be reported for a muscle spasm of the back.

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