Torticollis ICD-10 Code M43.6: Essential 2025 Billing Guidelines

Medical coding for torticollis ICD 10 needs more attention as 50 new ICD-10-PCS codes take effect on April 1, 2025. Next year's most important changes to medical coding include 252 new codes, 36 deletions, and 13 revisions throughout the ICD-10 system. Healthcare providers who treat this neck condition must stay up-to-date with these changes to receive proper reimbursement.

CMS data shows that clinics using laterality codes correctly face 20% fewer claim denials. This matters especially when you have torticollis-related billing. Your practice's bottom line can improve substantially with specific ICD 10 codes for torticollis, regardless of treating adults or babies with torticollis symptoms. The numbers speak for themselves - clinics that use correct coding practices see their revenue cycle efficiency jump by 25% while coding errors drop by 30%. This piece covers everything in the 2025 billing guidelines for torticollis treatment, with a focus on ICD-10-CM codes that matter most in outpatient physical therapy settings.

What does ICD-10 code M43.6 represent in 2025?

The M43.6 ICD-10 code stands for torticollis, a musculoskeletal condition that twists the neck and creates "wryneck." Healthcare providers can still bill this specific ICD-10-CM code in 2025 for reimbursement. The 2025 edition of ICD-10-CM M43.6 started on October 1, 2024, and will stay current through next year.

What is torticollis and what are its types?

Torticollis demonstrates itself when the neck twists and the head tips to one side while the chin rotates to the other. The condition happens because neck muscles contract involuntarily. These contracted cervical muscles force the head into an unnatural position.

Clinical practice recognizes three main types of torticollis:

1. Spasmodic Torticollis (Cervical Dystonia)
   
   • Adults are the main affected group
   • Painful, involuntary contractions turn or twist the head to one side
   • The head might also tilt forward or backward uncontrollably
2. Acquired Torticollis
   
   • Children get this most often, but adults can too
   • Shows up in the first four to six months after birth
   • Head tilting episodes come and go, sometimes with vomiting, irritability, or drowsiness
3. Congenital Muscular Torticollis
   
   • This type happens most often
   • Children are the main affected group
   • The head and face look asymmetrical
   • A short, tight sternocleidomastoid muscle (SCM) limits how much the head can move

How congenital and acquired torticollis are different

Type 1 Excludes notes show that M43.6 code doesn't include congenital torticollis. These notes mean you can't use both codes together because they're separate conditions. Babies develop congenital torticollis (Q68.0) either in the womb or from not enough tummy time and staying too long in swings or car seats.

Acquired torticollis is different from birth-related cases because it develops after birth. Trauma, inflammation, or other medical conditions can cause it. The M43.6 code doesn't cover torticollis from birth injury (P15.2) - that needs its own code.

Understanding M43.6 vs M43.5 vs G24.3

These ICD-10-CM codes have substantial differences:

Type 1 Excludes notes show that M43.6 and G24.3 can't be used together[63]. So patients with spasmodic torticollis need G24.3, not M43.6. This difference matters because treatments and insurance payments vary between these conditions.

M43.6 covers acquired torticollis that isn't from birth defects, birth injuries, or muscle spasms. It falls under Diagnostic Related Groups (MS-DRG v42.0): 551 Medical back problems with MCC or 552 Medical back problems without MCC.

Your 2025 billing needs careful attention to pick the right code based on your patient's exact type of torticollis.

How is medical necessity documented for torticollis claims?

Medical necessity documentation is the life-blood of successful torticollis ICD-10 code M43.6 claims. Healthcare providers need to clearly record specific clinical findings to justify treatment and secure reimbursement. Insurance carriers now want complete evidence before they approve claims related to torticollis treatment.

PART criteria: Pain, Asymmetry, Range of motion, Tissue tone

The PART assessment framework is the quickest way to document medical necessity in torticollis cases:

• Pain: Document both the presence and characteristics of pain, and note whether it's unilateral and radiates to the shoulder. Pain becomes the biggest reason patients seek medical attention, and it sometimes overshadows awareness of dystonic movements. Record if pain shows up during specific movements or positions.
• Asymmetry: Note any lateral tilt of the head in the frontal plane and contralateral rotation in the transverse plane. Document facial asymmetry since torticollis affects face symmetry and daily functioning.
• Range of motion (ROM): Review and record both active and passive cervical ROM using an arthrodial goniometer. Measure cervical lateral flexion, extension, and cervical rotation. Describe movement limitations and factors that ease restrictions.
• Tissue tone: Check and document the sternocleidomastoid muscle's condition, noting any fibrosis, shortening, or presence of a palpable mass. This examination is especially important since about 50% of cases get diagnostic confirmation within two months through physical examination.

Physical exam documentation for M43.6

Your physical examination documentation for torticollis claims using ICD-10 code M43.6 should include:

1. Detailed patient history covering symptom onset, characteristics (acute vs. chronic, painful vs. non-painful), and related symptoms like vomiting, fever, gait disturbances, or vision changes
2. Complete clinical examination findings including:
   
   • Patient posture evaluation
   • Constant or intermittent head tilt pattern
   • Movement limitations and factors that help
   • Bony or muscular tenderness when touched
3. Neurological assessment to rule out other conditions
4. Visual function assessment to determine if torticollis comes from a compensatory mechanism to improve vision
5. Hip examination findings, since about 15% of patients with congenital torticollis have associated hip dysplasias

Use of visual analog scales and palpation methods

Several proven assessment tools help calculate torticollis severity and document improvement over time:

Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS): This composite scale measures three aspects of cervical dystonia: severity (maximum 35 points), disability (maximum 30 points), and pain (maximum 20 points). Studies show substantial inter-rater agreement with Kendall's coefficient of concordance ranging from 0.76 to 0.98.

Visual Analog Scale (VAS): This patient-reported outcome measure uses a 0-10 scale to assess pain intensity. One case study showed pain reduction from 8 to 5 after treatment.

Tsui Score: This impairment scale reviews the extent and duration of neck, head, and shoulder movement, with scores ranging from 1 to 25—higher scores show more severe conditions.

These scales need careful palpation methods, with special attention to the sternocleidomastoid muscle for fibrosis, shortening, or the presence of a mass. Regular documentation of these findings between visits helps establish why ongoing torticollis treatment is needed.

Which ICD-10 codes support medical necessity for M43.6?

Getting reimbursed for torticollis treatment depends on choosing and arranging the right codes. ICD-10 coding system has specific ways to prove medical necessity through primary and secondary code combinations that support proper treatments.

Primary diagnosis: M43.6 - Torticollis

M43.6 serves as a billable diagnosis code that designates a medical diagnosis of torticollis. This code stays valid for HIPAA-covered transactions from October 01, 2024 through September 30, 2025. Healthcare providers must list M43.6 as the primary diagnosis code and specify the exact level of subluxation.

M43.6 belongs to the clinical category of "Spondylopathies/spondyloarthropathy (including infective)" with a CCSR Category Code of MUS011. This classification determines its diagnostic related grouping (DRG) and affects reimbursement rates. The code appears in these MS-DRG V42.0 groups:

These diagnostic groups' relative weight determines the reimbursement rate based on severity and care costs.

Secondary codes for associated symptoms (e.g., M62.838, M54.2)

Secondary codes are vital to establish complete medical necessity for torticollis treatment. These codes document symptoms and support therapeutic interventions. M43.6 pairs most often with these secondary codes:

• M62.838 - Other muscle spasm: This billable code captures muscle spasms in the neck region. It has multiple relevant conditions like "muscle spasm of cervical (neck) muscle," "muscle spasm of neck," and "muscle spasms of neck".
• M54.2 - Cervicalgia: Documents neck pain that comes with torticollis, which often brings patients to seek treatment.
• R29.891 - Ocular torticollis: Used when vision issues contribute to or result from torticollis.

A complete coding approach typically uses M43.6 as the primary diagnosis with M62.838 as a secondary code to document muscle spasms. CMS guidelines state that "neuromusculoskeletal condition necessitating the treatment must be listed as the secondary diagnosis".

Short-term vs long-term treatment code groupings

CMS Medicare Coverage Database groups treatment codes for conditions like torticollis based on predicted treatment duration. These groups establish treatment timelines and coverage parameters.

Short-term treatment codes (Group 2 codes) cover 48 conditions that need brief interventions. Key codes for torticollis management are:

• M54.2 - Cervicalgia
• M62.838 - Other muscle spasm
• M62.85 - Dysfunction of the multifidus muscles, lumbar region

Moderate-term treatment codes (Group 3 codes) have 193 conditions that need extended care. This group specifically has:

• M43.6 - Torticollis
• M54.12 - Radiculopathy, cervical region
• M79.18 - Myalgia, other site

Long-term treatment codes (Group 4 codes) list 70 conditions that need ongoing management. While M43.6 isn't in this group, many torticollis cases involve related conditions that are, such as:

• M48.01-M48.07 - Spinal stenosis (various regions)
• M54.31-M54.32 - Sciatica (right/left side)

The right code selection needs a full picture of the patient's condition. Babies with torticollis usually need M43.6 (torticollis, unspecified) or Q68.0 (congenital musculoskeletal deformities of sternocleidomastoid muscle) with age limits. Adult torticollis coding reflects its 90% lifetime prevalence and varied patterns.

What are the billing and modifier rules for torticollis services?

Medicare's torticollis treatment billing requirements need specific modifiers that affect reimbursement. Practitioners who treat torticollis with ICD-10 code M43.6 should know these rules to get proper payment and avoid claim denials.

AT modifier for active treatment

The AT (Active Treatment) modifier is a vital part of billing for torticollis treatment services. This modifier shows that:

• You give active/corrective treatment for acute or chronic torticollis, not maintenance care
• Your treatment targets a documented neuromusculoskeletal condition
• The services match Medicare's definition of medical necessity

Medicare wants the AT modifier on all claims for spinal manipulation treatment codes (98940, 98941, 98942) at the time of treating active torticollis. Claims with dates of service after October 1, 2004, will be denied without this modifier. Keep in mind that even with the AT modifier, your documentation must show active improvement. The treatment becomes maintenance and loses Medicare coverage once improvement plateaus.

GA modifier and ABN for non-covered services

The GA modifier becomes significant when your torticollis treatment might not meet Medicare's medical necessity criteria:

• The GA modifier shows you have a signed Advance Beneficiary Notice (ABN) on file
• Your ABN tells patients they'll need to pay if Medicare denies payment
• The GA modifier works with only covered services that Medicare might deny as not medically necessary

The GY modifier works better for statutorily excluded services. Medicare systems will automatically deny services with the GA modifier and transfer the financial responsibility to the patient. The GZ modifier indicates provider liability when you think Medicare won't cover services but don't have an ABN.

Required claim elements: DOS, POS, CPT, ICD-10

Your torticollis claim needs these key elements:

1. Date of Service (DOS): When you provided the treatment
2. Place of Service (POS): The location of service (office, outpatient facility, etc.)
3. Procedure Code (CPT): The right treatment code (usually 98940-98942 for manipulation)
4. Diagnosis Code (ICD-10): M43.6 as primary code with any secondary symptom codes
5. Date of treatment initiation: The start date of treatment
6. Symptom/condition codes: Secondary diagnosis codes that support medical necessity

Missing elements in claims lead to rejection or delayed processing. These billing guidelines will help you get proper reimbursement for torticollis treatment services.

What services are excluded from Medicare coverage for M43.6?

Medicare places strict limits on reimbursable services for torticollis ICD 10 code M43.6, even though it's a covered diagnosis. You should know these limitations to prevent claim denials and create sound financial policies for your practice.

Non-covered services: X-rays, office visits, physiotherapy

Medicare automatically denies many services that chiropractors perform for torticollis treatment, whatever the medical necessity documentation shows. CMS guidelines indicate these services face automatic denials:

• Laboratory tests
• X-rays and diagnostic imaging
• Office visits (history and physical examinations)
• Physiotherapy and rehabilitation services
• Traction and decompression therapy
• Medical supplies and equipment
• Injections and medication administration
• Diagnostic studies including EKGs
• Orthopedic devices and supports
• Nutritional supplements and counseling

Chiropractors don't need to bill these services to Medicare. Notwithstanding that, many practices must perform these vital components of torticollis care without any chance of reimbursement.

Extraspinal manipulation (CPT 98943) exclusion

Medicare's refusal to cover chiropractic treatments to extraspinal regions under CPT code 98943 stands out. This affects about 30% of claims for extraspinal procedures. Torticollis patients face a major challenge since their condition typically involves:

• Head positioning corrections
• Upper extremity compensatory treatments
• Rib cage manipulation for associated breathing patterns
• Abdominal muscle work for postural support

Standard Medicare programs maintain this limitation consistently, though some Medicare Advantage plans might offer better coverage.

When to submit for denial to secondary insurers

Smart claim submissions can help despite coverage limits. Medicare won't cover excluded services, but getting formal denials often helps with secondary insurance processing.

The process works best when you:

1. Submit non-covered services separately from covered treatments
2. Apply the GY modifier to indicate statutorily excluded services
3. Document patient's understanding of Medicare's non-coverage through proper ABNs

Secondary insurers usually want Medicare's denial before they'll look at claims—especially for adults with chronic torticollis. This coordination process takes extra work but helps maximize reimbursement through other payment options.

Conclusion

What should you remember about torticollis coding for 2025?

Healthcare's transition to the 2025 ICD-10 updates makes accurate torticollis coding crucial for clinical practice. This piece shows how proper documentation affects reimbursement. Clinics that use correct coding practices see 25% better revenue cycle efficiency and 30% fewer coding errors.

M43.6 represents acquired torticollis, which is different from congenital (Q68.0) and spasmodic (G24.3) variants. This difference matters because each condition needs its own treatment approach and has unique reimbursement implications. The PART criteria (Pain, Asymmetry, Range of motion, Tissue tone) helps establish medical necessity for treatment authorization through detailed documentation.

Proper modifier usage can affect your claim outcomes by a lot. The AT modifier shows active treatment, while the GA modifier acknowledges potential non-coverage with an Advance Beneficiary Notice on file. Medicare excludes several services like X-rays, office visits, physiotherapy, and extraspinal manipulation. Knowing these exclusions helps you avoid denial surprises and create appropriate financial policies.

Staying up-to-date with coding details protects your practice's finances and ensures quality patient care. Knowing how to use these guidelines determines your reimbursement success and documentation quality. The 2025 changes might be challenging, but they give you a chance to improve your practice's coding procedures and efficiency.

FAQs

Q1. What is the ICD-10 code for torticollis in 2025?

The ICD-10 code for torticollis in 2025 is M43.6. This code represents acquired torticollis and is distinct from codes for congenital or spasmodic variants.

Q2. How should medical necessity be documented for torticollis claims?

Medical necessity for torticollis claims should be documented using the PART criteria: Pain, Asymmetry, Range of motion, and Tissue tone. This comprehensive assessment helps establish the need for treatment and supports reimbursement claims.

Q3. What modifiers are important when billing for torticollis treatment?

Two key modifiers for torticollis billing are the AT modifier, which indicates active treatment, and the GA modifier, used when there's a signed Advance Beneficiary Notice on file for potentially non-covered services.

Q4. Are there any services excluded from Medicare coverage for torticollis?

Yes, Medicare excludes several services for torticollis treatment, including X-rays, office visits, physiotherapy, and extraspinal manipulation (CPT 98943), regardless of medical necessity documentation.

Q5. How does proper torticollis coding impact a medical practice?

Proper torticollis coding can significantly impact a medical practice by increasing revenue cycle efficiency by 25% and reducing coding errors by 30%. It also ensures appropriate reimbursement and helps maintain high-quality clinical documentation.

‍