Find comprehensive information on torticollis diagnosis, including clinical documentation tips, ICD-10-CM codes (M99.0), congenital muscular torticollis, acquired torticollis, and treatment options. This resource helps healthcare professionals accurately document and code torticollis for optimal patient care and reimbursement. Learn about associated symptoms, physical exam findings, differential diagnoses, and best practices for managing torticollis in infants, children, and adults.
Also known as
Torticollis
Includes congenital and acquired torticollis.
Congenital musculoskeletal deformities of head, face and neck
Covers congenital torticollis as a specific birth defect.
Other abnormal involuntary movements
May include spasmodic torticollis as an abnormal movement.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the torticollis congenital?
Yes
Is it due to birth injury?
No
Is a specific cause documented?
When to use each related code
| Description |
|---|
| Head tilt/rotation due to SCM muscle tightness |
| Abnormal head posture due to bone abnormality |
| Spasmodic neck muscle contractions |
Incorrectly coding the affected side (left, right, or unspecified) for torticollis can lead to claim denials and inaccurate data.
Failure to distinguish between congenital and acquired torticollis (e.g., using M99.0 with specific cause documented) impacts quality reporting.
Using a generic torticollis code (e.g., M43.6) when a more specific diagnosis is documented (e.g., spasmodic torticollis) loses clinical detail.
Patient presents with torticollis, characterized by a twisted neck and tilted head. Differential diagnosis includes congenital muscular torticollis, acquired torticollis, and spasmodic torticollis. Onset of symptoms was [Date/Duration]. Associated symptoms may include neck pain, stiffness, limited range of motion, headache, shoulder elevation, and a palpable neck mass or tightness in the sternocleidomastoid muscle (SCM). Physical examination revealed head tilt to the [Affected Side] side and chin rotation to the [Opposite Side] side. The degree of head tilt was measured and documented. Palpation of the SCM revealed [Muscle tightness/mass/no abnormalities]. Neurological examination was unremarkable. Assessment includes congenital torticollis vs. acquired torticollis. Current treatment plan includes physical therapy focusing on stretching and range of motion exercises. Patient education provided on home exercises and proper positioning. Follow-up scheduled in [Duration] to assess treatment response and consider further interventions such as botulinum toxin injections or surgical intervention if indicated. ICD-10 code [Appropriate ICD-10 code, e.g., M43.6 for adult acquired torticollis, Q68.0 for congenital muscular torticollis] is being considered. CPT codes for evaluation and management (E/M) and physical therapy (PT) will be billed according to the services provided.