M86.611
BillableOther chronic osteomyelitis, right shoulder
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is M86.611 an HCC code?
Yes. M86.611 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 M86.611
For M86.611 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 M86.611 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
M86.611 is the ICD-10-CM diagnosis code for other chronic osteomyelitis, right shoulder. A long-term bone infection in the right shoulder area. M86.611 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, M86.611 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, M86.611 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.
Confirm right shoulder is the documented site of infection. Because M86.611 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 M86.611 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Confirm right shoulder is the documented site of infection
- •Distinguish from hematogenous osteomyelitis by verifying the infection origin in documentation
Clinical Significance
Chronic osteomyelitis of the right shoulder represents a persistent bone infection that significantly impacts upper extremity function and activities of daily living. The shoulder's complex anatomy and critical role in arm mobility make this condition particularly debilitating, often requiring specialized orthopedic management and extended rehabilitation.
Documentation Requirements
- ✓Documentation of chronic duration (>6 weeks or recurrent episodes)
- ✓Specific involvement of right shoulder bones (humerus, scapula, or clavicle)
- ✓Non-hematogenous etiology (contiguous spread or direct inoculation)
- ✓Imaging studies showing bone infection or destruction
- ✓Laboratory evidence of infection or inflammatory response
- ✓Assessment of shoulder range of motion and functional limitations
- ✓Documentation of treatment including antibiotics and surgical interventions
- ✓Evaluation of impact on activities of daily living