M86.519
BillableOther chronic hematogenous osteomyelitis, unspecified shoulder
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is M86.519 an HCC code?
Yes. M86.519 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 M86.519
For M86.519to 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 M86.519 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
M86.519 is the ICD-10-CM diagnosis code for other chronic hematogenous osteomyelitis, unspecified shoulder. A chronic bone infection of the shoulder from a bloodstream source when the specific side (left or right) is not documented. M86.519 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, M86.519 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, M86.519 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.
Use this code only when laterality cannot be determined from the medical record. Because M86.519 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 M86.519 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Use this code only when laterality cannot be determined from the medical record
- •Query the provider if documentation is ambiguous about which shoulder is affected to allow for more specific coding
Clinical Significance
Other chronic hematogenous osteomyelitis of unspecified shoulder indicates a blood-borne bone infection that has become chronic with shoulder involvement but without laterality specification. This condition represents systemic infection with localized bone manifestation requiring prolonged treatment, though the unspecified nature may limit precise treatment planning and functional assessment.
Documentation Requirements
- ✓Clear documentation of chronic osteomyelitis diagnosis
- ✓Evidence of hematogenous (blood-borne) etiology
- ✓Shoulder involvement specified without laterality designation
- ✓Laboratory evidence of systemic infection process
- ✓Blood cultures or markers indicating hematogenous spread
- ✓Treatment history and current antibiotic regimens
- ✓Imaging studies confirming shoulder bone infection
- ✓Assessment of treatment response and functional status
Commonly Confused Codes
- •M86.511 — Other chronic hematogenous osteomyelitis, right shoulder (has laterality)
- •M86.512 — Other chronic hematogenous osteomyelitis, left shoulder (has laterality)
- •M86.619 — Other chronic osteomyelitis, unspecified shoulder (not specifically hematogenous)
- •M86.319 — Chronic multifocal osteomyelitis, unspecified shoulder (multifocal pattern)