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M86.511 ICD-10-CM Code: Other chronic hematogenous osteomyelitis, right shoulder

M86.511 maps to CMS-HCC V28 92 (RAF 0.479). Documentation must support MEAT. MEAT criteria · RAF calculator · HCC Buddy coding tools

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FY 2026 Apr update / Diseases of the musculoskeletal system and connective tissue (M00-M99) / Other osteopathies (M86-M90)

M86.511

Billable / SpecificICD-10-CMOfficial ICD-10-CMCodebook guidance

Other chronic hematogenous osteomyelitis, right shoulder

A chronic bone infection of the right shoulder that developed from a bloodstream infection.

Buddy the Bee presenting code insight

Buddy Insight

Other chronic hematogenous osteomyelitis of the right shoulder indicates a blood-borne bone infection that has become chronic, specifically affecting the right shoulder complex.

CMS-HCC V28

HCC 92

RAF 0.479

CMS-HCC V24

HCC 39

RAF 0.401

ACA/HHS

HCC 55

Varies by metal level

ESRD/PACE

HCC 39

RAF 0.092

RXHCC

N/A

—

Not mapped

Code Book Path

Official
M86.5Other chronic hematogenous osteomyelitis
M86.51Other chronic hematogenous osteomyelitis, shoulder
M86.511Other chronic hematogenous osteomyelitis, right shoulder

Inclusion Terms

Official

ICD-10-CM does not list inclusion terms for M86.511 in this effective period.

Excludes 2

Official

ICD-10-CM does not list Excludes 2 notes for M86.511 in this effective period.

Related Child Codes

Official
M86.512Other chronic hematogenous osteomyelitis, left shoulder
M86.519Other chronic hematogenous osteomyelitis, unspecified shoulder

Includes

Official

ICD-10-CM does not list Includes notes for M86.511 in this effective period.

Excludes 1

Official

ICD-10-CM does not list Excludes 1 notes for M86.511 in this effective period.

Code First

Official

ICD-10-CM does not list Code First sequencing instructions for M86.511 in this effective period.

Use Additional

Official

ICD-10-CM does not list Use Additional Code instructions for M86.511 in this effective period.

Code Also

Official

ICD-10-CM does not list Code Also instructions for M86.511 in this effective period.

Buddy Documentation Tip

HCC Buddy guidance
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

MEAT Support

HCC Buddy guidance
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

Audit Caution

HCC Buddy guidance
Confusing laterality when coding shoulder involvement
Missing the hematogenous specification when blood-borne origin is documented
Using multifocal codes when single-site hematogenous infection is present
Failing to distinguish between different chronic osteomyelitis types

Common Mistakes

HCC Buddy guidance
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)

Current with CMS: FY2026 ICD-10-CM Apr 1 update (effective Apr 1 – Sep 30, 2026) · CMS-HCC V28, 100% phased in for payment year 2026. FY2027 code set already staged for October 1, 2026. How HCC Buddy stays current →

Is M86.511 an HCC code?

Yes. M86.511 (Other chronic hematogenous osteomyelitis, right shoulder) 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), with a community non-dual aged RAF of 0.479. It is billable for payment year 2026.

Coder answer: M86.511 is billable and maps to V28 HCC 92, Bone/Joint/Muscle/Severe Soft Tissue Infections/Necrosis. Open it in the Code Book for the tabular path, RAF, and MEAT checklist.

Code
M86.511
Description
Other chronic hematogenous osteomyelitis, right shoulder
HCC (V28)
HCC 92 — Bone/Joint/Muscle/Severe Soft Tissue Infections/Necrosis
RAF
0.479
Billable
Yes
Payment year
2026

HCC Category Mapping

V28HCC 92, Bone/Joint/Muscle/Severe Soft Tissue Infections/Necrosis
0.479
V24HCC 39, Bone/Joint/Muscle Infections/Necrosis
0.401
ESRDHCC 39, Bone/Joint/Muscle Infections/Necrosis
0.092

Each model's RAF is its CMS base weight for that model's standard population, so weights are not directly comparable across models: CMS-HCC V28 and V24 use Community, Non-Dual, Aged; ESRD uses the dialysis continuing-enrollee model; RxHCC is the Part D continuing-enrollee, non-low-income, aged weight (a larger scale than CMS-HCC). ACA/HHS has no single weight — it varies by metal level. 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.

Work M86.511 in the Code Book — tabular path, V28 RAF, and MEAT checklist →

MEAT Criteria for M86.511

For M86.511 to 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.

Coder workflow notes

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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/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, M86.511 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.

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

  • •This code is specific to the right shoulder; use M86.512 for left shoulder or M86.519 if laterality is not documented
  • •Document the shoulder bone affected (humerus, scapula, or clavicle) in the medical record for clarity

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)

Child Codes

M86.511Other chronic hematogenous osteomyelitis, right shoulder
HCC 92
M86.512Other chronic hematogenous osteomyelitis, left shoulder
HCC 92
M86.519Other chronic hematogenous osteomyelitis, unspecified shoulder
HCC 92

Code Hierarchy

└M86Osteomyelitis└M86.5Other chronic hematogenous osteomyelitis└M86.51Other chronic hematogenous osteomyelitis, shoulder└M86.511Other chronic hematogenous osteomyelitis, right shoulder
└M86.511Other chronic hematogenous osteomyelitis, right shoulder

Because M86.511 maps to a payment HCC, the documentation must also satisfy MEAT criteria (Monitor, Evaluate, Assess, or Treat) for the encounter to count toward the patient's risk adjustment score.

M86.511 maps to CMS-HCC V28 category 92, Bone/Joint/Muscle/Severe Soft Tissue Infections/Necrosis. See the ICD-10 to HCC mapping hub for how the V28 crosswalk works. Because M86.511 carries a payment HCC, you can see what it adds to a RAF score and check the documentation the chart needs before it is submitted.

Work M86.511 in HCC Buddy

Open M86.511 in the Code Book for the full Index-to-Tabular path, MEAT checklist, and V28 HCC mapping, or in the Encoder to code from a keyword search. Pro includes 7 days to try everything, no card required.

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