Nontraumatic separation or diastasis of muscle at an unspecified body site — use only when the affected site is not documented anywhere in the encounter record.
Verified May 8, 2026 · 4 sources ↓
- Status
- Billable
- Chapter
- 13
- Related CPT
- 6
- Region
- General
Documentation tips
What should appear in the chart to support M62.00.
Source · Editorial brief grounded in 4 cited references ↓
- Record the specific anatomical site by name in every encounter note — shoulder, upper arm, forearm, thigh, etc. — so a site-specific M62.0x code can be used instead of M62.00.
- Distinguish the mechanism explicitly: document 'nontraumatic' or 'atraumatic' onset to keep this code family valid and avoid defaulting to a strain code.
- If imaging (MRI, ultrasound) was performed, reference the radiologist's description of the muscle separation site and extent in the clinical note to support the diagnosis.
- For any diastasis recti identified during pregnancy, labor, or delivery, document the obstetric context so coders can correctly redirect to O71.8 rather than M62.00.
- Note whether conservative care has been attempted (physical therapy, bracing) — this supports medical necessity for ongoing evaluation and any planned procedural intervention.
Related CPT procedures
Procedure codes commonly billed with M62.00. Linking the right diagnosis to the right procedure is what establishes medical necessity.
Source · CMS LCDs · AAOS specialty guidance · claims-pattern analysis
Common coding pitfalls
The recurring mistakes coders make with M62.00 and adjacent codes.
Source · Editorial brief grounded in CDC ICD-10-CM tabular guidance, AAOS coding references, and cited references ↓
- Using M62.00 when a site is actually documented elsewhere in the record — operative notes, imaging reports, or the HPI frequently name the body region; always check all encounter documents before defaulting to unspecified.
- Coding M62.00 for traumatic muscle separations — the Excludes1 note at M62.0 prohibits this; traumatic separation codes as a muscle strain by the specific body region.
- Confusing M62.00 with nontraumatic muscle hematoma — M79.81 is the correct code for hematoma and is listed as an Excludes2 at the M62 category level; both codes can be reported together when both conditions are documented, but they are not interchangeable.
- Billing M62.0 (the non-billable parent) instead of M62.00 — M62.0 is not valid for claim submission; M62.00 is the billable child code when site is unspecified.
Clinical context
Source · Editorial summary grounded in 4 cited references ↓
M62.00 covers nontraumatic muscle separation (diastasis) when the clinical documentation fails to identify a specific anatomical site. The M62.0 parent category includes diastasis of muscle — an abnormal widening or splitting of a muscle belly without a traumatic mechanism. The most familiar clinical example is diastasis recti, though that specific presentation in pregnancy or delivery is excluded here (see O71.8). Traumatic muscle separation is also excluded from this category; if trauma caused the separation, code it as a muscle strain by body region instead.
M62.00 is the last-resort code within the M62.0 family. Site-specific child codes exist for shoulder (M62.01x), upper arm (M62.02x), forearm (M62.03x), and other regions, each with right/left/unspecified laterality options. If the operative report, imaging read, or clinical note names any anatomical site — even generally — use the more specific code. M62.00 is appropriate only when site documentation is genuinely absent from the entire encounter record.
In orthopedic practice, this code may appear in contexts such as postoperative muscle gapping, spontaneous diastasis in the setting of chronic systemic disease, or prolonged immobilization — all nontraumatic in origin. Payers may scrutinize M62.00 due to its low specificity; audit risk is elevated any time an unspecified-site code is submitted alongside a procedure that implies a known operative field.
Sibling codes
Other billable codes under M62.0 (laterality / anatomic variants).
Frequently asked questions
Source · Generated from the editorial pipeline, verified against 4 cited references ↓
01When is M62.00 the correct code rather than a more specific M62.0x child code?
02Can M62.00 be used for diastasis recti?
03A patient sustained a muscle separation during a fall. Does M62.00 apply?
04Is M62.0 billable, or must coders use M62.00?
05Can M62.00 and M79.81 be coded together on the same claim?
06What CPT procedures are most commonly paired with M62.00 in orthopedic practice?
Sources & references
Editorial content was developed using the following public sources. Last verified May 8, 2026.
- 01CDC ICD-10-CM Tabular List 2026 (effective Oct 1, 2025)
- 02icd10data.comhttps://www.icd10data.com/ICD10CM/Codes/M00-M99/M60-M63/M62-/M62.00
- 03aapc.comhttps://www.aapc.com/codes/icd-10-codes/M62.00
- 04aapc.comhttps://www.aapc.com/codes/coding-newsletters/my-orthopedic-coding-alert/icd-10-update-icd-10-gets-specific-for-diastasis-of-muscle-111142-article
Mira AI Scribe
Mira's AI scribe captures the muscle separation site from the provider's dictation, physical exam findings, and any linked imaging report, then flags if site documentation is missing before claim submission — preventing automatic downgrade to the unspecified M62.00 and reducing audit exposure on claims where a site-specific code was available but not coded.
See how Mira captures M62.00 documentation