M02.811
BillableOther reactive arthropathies, right shoulder
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is M02.811 an HCC code?
Yes. M02.811 maps to Bone/Joint/Muscle Infections/Necrosis under the CMS-HCC V28 risk adjustment model (and Bone/Joint/Muscle Infections/Necrosis under V24).
HCC Category Mapping
RAF weights shown are the community, non-dual, aged base weights from the CMS risk adjustment model file. Actual per-patient RAF contribution depends on member segment, interactions, and the model year used by the payer. V28 is the CMS-HCC model phased in over payment years 2024–2026; V24 remains in use during the transition and for historical data.
MEAT Criteria for M02.811
For M02.811to count as a valid HCC diagnosis in a given encounter, the provider's documentation must show MEAT: Monitor, Evaluate, Assess, or Treat. A diagnosis from a prior year does not carry forward automatically — it has to be re-documented and supported each calendar year.
- MMonitor: signs, symptoms, disease progression, or lab trending documented in the note
- EEvaluate: test results, medication response, or physical findings reviewed by the provider
- AAssess: explicit mention in the assessment or plan with acknowledgment of status
- TTreat: medication, referral, procedure, therapy, or counseling tied to the diagnosis
Only one of M/E/A/T is required to support the code, but the documentation must be specific enough to show that the provider actually addressed M02.811 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
M02.811 is the ICD-10-CM diagnosis code for other reactive arthropathies, right shoulder. Joint inflammation of the right shoulder caused by a reaction to infection elsewhere in the body. M02.811 sits in the ICD-10-CM chapter for diseases of the musculoskeletal system and connective tissue (m00-m99), within the section covering infectious arthropathies (m00-m02).
Under the CMS-HCC V28 risk adjustment model, M02.811 maps to Bone/Joint/Muscle Infections/Necrosis (HCC 92) with a community, non-dual, aged base RAF weight of 0.209. Under the older V24 model, M02.811 mapped to the same category but with a base RAF weight of 0.482 — V28 recalibrated weights across the entire model. V28 is the CMS-HCC risk adjustment model that reached 100% phase-in for payment year 2026, replacing V24 which was used during the PY2024–PY2025 transition.
Ensure documentation specifies 'right' shoulder to justify this laterality code. Because M02.811 maps to a payment HCC, the provider's documentation must satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's Medicare Advantage risk adjustment score. When documentation is ambiguous, coders should issue a provider query rather than assume the highest-specificity variant.
HCC Buddy maintains structured V28 and V24 mapping, RAF weights, and MEAT documentation criteria for M02.811 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Ensure documentation specifies 'right' shoulder to justify this laterality code
- •Link to the causative infection in the medical record for clinical clarity
Clinical Significance
Other reactive arthropathies affecting the right shoulder represents joint inflammation secondary to bacterial infection elsewhere in the body, significantly impacting upper extremity function and range of motion. This condition requires ongoing anti-inflammatory management and has important implications for patient functional status and care costs.
Documentation Requirements
- ✓Specific documentation of right shoulder joint involvement
- ✓Evidence of reactive arthropathy secondary to bacterial infection
- ✓Physical examination findings of shoulder inflammation and limited range of motion
- ✓History of precipitating infection (genitourinary, gastrointestinal, respiratory)
- ✓Laboratory evidence of inflammatory markers
- ✓Assessment of upper extremity function and activities of daily living
- ✓Treatment response to anti-inflammatory medications
- ✓Exclusion of other specific shoulder arthropathies
Commonly Confused Codes
- •M75.31 — Calcific tendinitis of right shoulder affects tendons rather than joints
- •M19.011 — Primary osteoarthritis of right shoulder is degenerative condition
- •M25.511 — Pain in right shoulder is symptomatic rather than diagnostic
- •M02.321 — Reiter's disease of right elbow affects different joint and has specific diagnosis