Spasticity ICD 10 code

Spasticity ICD 10 codes are diagnosis and insurance billing codes referring to involuntary muscle contraction with movement or at rest. Spasticity is a result of central nervous system damage including the brain, spinal cord, and nerves.

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It is a neuromuscular condition that can present with hypertonia (high muscle tone), contractures, pain, stiffness, and/or muscle spasms. Conditions such as a brain injury, stroke, cerebral palsy (CP), multiple sclerosis (MS), and a spinal cord injury (SCI) can all present with spasticity.

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Spasticity affects muscles in any part of the body, but is most common in the legs with symptoms varying among individuals. It can be painful, disfiguring and disabling.

Spasticity can impact one’s occupational performance and daily functioning. It may affect mobility, social and emotional well-being, energy levels, pain levels, and the ability to perform ADL tasks such as bathing, dressing, feeding, grooming, and hygiene. We’ll look at Spasticity ICD 10 codes along with assessment and evaluation, treatment and professional collaboration.

Spasticity ICD 10 codes

The International Classification of Diseases (ICD) aims to promote international comparability in collecting, processing, classifying, and presenting mortality statistics.

The use of proper Spasticity ICD-10 codes can aid in improving comprehension risk and severity. It’s important to incorporate proper Spasticity ICD 10 codes to ensure reimbursement, medical necessity, and continued care.

In occupational therapy practice, the ICD-10 is a billable/specific code that can be used for diagnosis for reimbursement purposes. Utilizing Spasticity ICD 10 codes that are client-specific is important as they improve the overall quality of care and management. It is important to note that many clinicians will utilize diagnosis codes such as cerebral palsy, stroke, multiple sclerosis, etc, along with spasticity ICD codes, if applicable to the client.

Some of the different Spasticity ICD 10 codes can be found in the chart below. It is important to note that this is not an all-encompassing list of Spasticity ICD 10 codes and simply serves as a reference tool.

ICD-10 Code

Spasticity Type

G81.10

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Spastic hemiplegia affecting unspecified side

G81.11

Spastic hemiplegia affecting right dominant side

G81.12

Spastic hemiplegia affecting left dominant side

G80.0

Spastic quadriplegic cerebral palsy

G80.1

Spastic diplegic cerebral palsy

I69.398

Other sequelae of cerebral infarction

(approximate synonym for spasticity due to stroke)

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*All Spasticity ICD 10 Codes from ICD10data.com

Assessment and evaluation of individuals with Spasticity

Occupational therapists play a crucial role in assessing and evaluating individuals with spasticity. Therapists perform comprehensive evaluations starting with a detailed history, understanding current ADL function level, perform skilled clinical observation, assess for strength and range of motion utilize standardized assessments, and assess the need for adaptive equipment and assistive technology if applicable.

Based on the severity of spasticity, an evaluation may also include the need for mobility devices, adaptive equipment such as adaptive utensils, splints, orthotic devices, and/or ergonomic and safety modifications to the home, work, and school environment.

Standardized assessments to assess for spasticity can be found below:

• Modified Ashworth Scale:
  • Ages 6-12, 18-64
  • Scores range from 0-4, with 6 choices
  • 0 refers to no change in muscle tone with 4 referring to the affected part, rigid in flexion/extension
• Tardieu Scale/Modified Tardieu Scale:
  • Tardieu is a scale for measuring spasticity that accounts for resistance to passive movement at different speeds including slow and fast
  • Grades 0-4=no resistance with passive movement; 4=infatigable clonus
  • Individuals are tested in a seated position to test the UEs and supine test the LEs.

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Occupational therapy interventions for Spasticity management

Occupational therapists play a pivotal role in the intervention and management of spasticity. Depending on the level of severity of spasticity, therapists will provide interventions to improve independence with ADL tasks, include task-specific training, perform range of motion exercises, stretching, splinting, provide education, and may also focus on social-emotional regulation/coping strategies.

Therapists may also incorporate functional electrical stimulation and/or neuromuscular electrical stimulation as part of the treatment plan if applicable to the client. Research has found that electrical stimulation may improve spasticity, muscle mass and strength, upper extremity function, passive range of motion (PROM),walking speed, and positioning of the foot and ankle kinematics during walking.

It is crucial to understand that each person with spasticity is unique and presents with unique challenges and strengths. There is no one-size-fits-all approach for spasticity management, and some interventions may apply to some individuals and may not be a good fit. It is important to develop individualized treatment plans based on evaluation findings and each client’s unique profile and history.

Assistive devices for Spasticity

Based on assessment findings as well as considering age, environmental factors, and client preferences, occupational therapists will collaborate with the client and select and educate clients on appropriate assistive devices. This may include assistive devices to increase independence with ADL tasks such as such as adaptive feeding utensils and cups, assistive devices for extremities such as braces or orthotics, mobility devices such as walkers, canes, or wheelchairs, pressure relief cushions to prevent sores, and driving aids.

Collaborative care and multidisciplinary approach for Spasticity

Collaborative care and a multidisciplinary approach are key for the treatment and management of spasticity. Occupational therapists will often work beside physical therapists, speech therapists, assistive technology specialists, and/or counselors, to address the physical, emotional, cognitive, psychological, and social aspects of care.

To address the underlying causes of spasticity, occupational therapists may collaborate with doctors for medication management, surgeons, and physical medicine specialists. By including a team of healthcare professionals who are experts in their field, it advocates for the need of comprehensive services, addressing the unique needs and the functional outcomes of the individual. Collaboration also ensures coordination of care, interventions being integrated, and proper education and support being provided.

Spasticity education and prevention strategies

An important part of occupational therapy intervention for spasticity is providing education and strategies for prevention. Education allows for individuals and family members to feel empowered and take charge of their diagnoses and treatment, prevent complications, optimize functional status, and improve an individual’s quality of life. Promoting awareness of preventive measures and early intervention approaches is also a crucial aspect to care.

Collaborating with other healthcare professionals, following evidenced-based practices and research, providing community education on spasticity as well as on early intervention therapy services, encouraging movement and exercise as well as following optimal movement and positioning protocols are all essential aspects of comprehensive treatment, education, and prevention of further spasticity related complications.

Furthermore, providing intervention and education for ergonomic and safety environmental modifications, home exercise programming focusing on range of motion and task-specific training, assistive devices, support groups, community resources, and counseling resources, are all important aspects of providing comprehensive, holistic, and client-centered care that lead to positive client-outcomes.

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