M02.819
BillableOther reactive arthropathies, unspecified shoulder
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is M02.819 an HCC code?
Yes. M02.819 maps to Bone/Joint/Muscle/Severe Soft Tissue 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 M02.819
For M02.819to 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 M02.819 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
M02.819 is the ICD-10-CM diagnosis code for other reactive arthropathies, unspecified shoulder. Joint inflammation of the shoulder caused by a reaction to infection, when the specific side (left or right) is not specified. M02.819 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, M02.819 maps to Bone/Joint/Muscle/Severe Soft Tissue Infections/Necrosis (HCC 92) with a community, non-dual, aged base RAF weight of 0.479. Under the older CMS-HCC V24 model, M02.819 maps to Bone/Joint/Muscle Infections/Necrosis (HCC 39) with a community, non-dual, aged base RAF weight of 0.401. 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.
Use only when laterality cannot be determined from documentation. Because M02.819 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 M02.819 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Use only when laterality cannot be determined from documentation
- •Query the provider if shoulder involvement is documented but side is unclear
Clinical Significance
Other reactive arthropathies of unspecified shoulder represents joint inflammation secondary to bacterial infection when shoulder laterality cannot be determined or bilateral involvement exists. This condition significantly impacts upper extremity function and requires ongoing management with implications for patient functional status.
Documentation Requirements
- ✓Documented reactive arthropathy involving shoulder joint(s)
- ✓Clinical rationale for unspecified laterality or bilateral shoulder involvement
- ✓Evidence of bacterial infection preceding joint inflammation
- ✓Assessment of shoulder joint inflammation and mobility restrictions
- ✓Laboratory evidence supporting inflammatory arthritis
- ✓Functional evaluation of upper extremity capabilities
- ✓Treatment plan with anti-inflammatory medications
- ✓Exclusion of other specific shoulder arthropathies
Commonly Confused Codes
- •M75.30 — Calcific tendinitis of unspecified shoulder affects tendons not joints
- •M19.019 — Primary osteoarthritis of unspecified shoulder is degenerative disease
- •M25.519 — Shoulder pain, unspecified represents symptom rather than diagnosis
- •M53.2 — Spinal instabilities affect spine rather than shoulder joints