M87.263
BillableOsteonecrosis due to previous trauma, unspecified tibia
Last updated: FY2026 ICD-10-CM (Oct 1, 2025 – Sep 30, 2026) | CMS-HCC V28 (100% phase-in, PY2026)
Is M87.263 an HCC code?
Yes. M87.263 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 M87.263
For M87.263 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 M87.263 during that encounter — not just copy-forwarded from a problem list.
What This Code Means
M87.263 is the ICD-10-CM diagnosis code for osteonecrosis due to previous trauma, unspecified tibia. Death of bone tissue in the shinbone (tibia) caused by previous trauma, but the specific side (left or right) is not specified or documented. M87.263 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, M87.263 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, M87.263 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.
Query the provider to determine laterality when not documented; this unspecified code should be used only when side cannot be determined. Because M87.263 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 M87.263 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coding Tips
- •Query the provider to determine laterality when not documented; this unspecified code should be used only when side cannot be determined
- •Review operative reports or imaging studies that may indicate which tibia is affected
Clinical Significance
Unspecified tibial osteonecrosis following trauma indicates major weight-bearing bone pathology with significant implications for patient mobility and functional capacity. This condition requires specialized orthopedic care and comprehensive rehabilitation to optimize outcomes and prevent further complications.
Documentation Requirements
- ✓Documentation of tibia involvement without specified laterality
- ✓Clear history of previous trauma to lower leg area
- ✓Evidence of bone necrosis in tibial structures
- ✓Justification for unspecified laterality (bilateral involvement or unclear documentation)
- ✓Current ambulation status and weight-bearing capacity
- ✓Functional assessment and mobility limitations
- ✓Treatment planning and orthopedic consultation
- ✓Impact on patient independence and daily activities
Commonly Confused Codes
- •M87.261 — Osteonecrosis due to previous trauma, right tibia (when laterality is documented)
- •M87.262 — Osteonecrosis due to previous trauma, left tibia (when laterality is documented)
- •M87.363 — Other secondary osteonecrosis, unspecified tibia (non-traumatic cause)
- •M87.266 — Osteonecrosis due to previous trauma, unspecified fibula (different bone)
- •M84.369A — Stress fracture, unspecified tibia (acute injury, not chronic necrosis)