M86.511
BillableOther chronic hematogenous osteomyelitis, right shoulder
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is M86.511 an HCC code?
Yes. M86.511 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 M86.511
For M86.511to 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 M86.511 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
M86.511 is the ICD-10-CM diagnosis code for other chronic hematogenous osteomyelitis, right shoulder. A chronic bone infection of the right shoulder that developed from a bloodstream infection. M86.511 sits in the ICD-10-CM chapter for diseases of the musculoskeletal system and connective tissue (m00-m99), within the section covering other osteopathies (m86-m90).
Under the CMS-HCC V28 risk adjustment model, M86.511 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, M86.511 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.
This code is specific to the right shoulder; use M86.512 for left shoulder or M86.519 if laterality is not documented. Because M86.511 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 M86.511 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
Clinical Significance
Other chronic hematogenous osteomyelitis of the right shoulder indicates a blood-borne bone infection that has become chronic, specifically affecting the right shoulder complex. This condition represents systemic infection with localized bone involvement requiring prolonged antibiotic therapy and careful monitoring, significantly impacting upper extremity function and patient quality of life.
Documentation Requirements
- ✓Clear documentation of chronic osteomyelitis diagnosis
- ✓Evidence of hematogenous (blood-borne) origin or spread
- ✓Specific anatomic identification of right shoulder involvement
- ✓Laboratory evidence of systemic infection or positive blood cultures
- ✓Confirmation of chronic duration and persistence
- ✓Treatment history including IV antibiotic protocols
- ✓Imaging studies showing right shoulder bone infection
- ✓Assessment of shoulder function and treatment response
Commonly Confused Codes
- •M86.512 — Other chronic hematogenous osteomyelitis, left shoulder (wrong laterality)
- •M86.611 — Other chronic osteomyelitis, right shoulder (not specifically hematogenous)
- •M86.311 — Chronic multifocal osteomyelitis, right shoulder (multifocal pattern)
- •M86.411 — Chronic osteomyelitis with draining sinus, right shoulder (has draining sinus)