What is ICD-10 code M96.65?

M96.65 is the ICD-10-CM diagnosis code for Fracture of pelvis following insertion of orthopedic implant, joint prosthesis, or bone plate. A fracture of the pelvis that develops as a complication after surgical insertion of an orthopedic implant, joint prosthesis, or bone plate. M96.65 is a billable code, meaning it can be reported on a claim as a primary or secondary diagnosis when supported by documentation. M96.65 is part of the FY2026 ICD-10-CM code set published by the CMS National Center for Health Statistics and used on Medicare, Medicaid, and commercial claims in the United States.

Yes. M96.65 is a billable ICD-10-CM code that can be reported on professional and institutional claims as a primary or secondary diagnosis when the provider documentation supports the specific condition described. Billable codes in ICD-10-CM are coded to the highest level of specificity available for the documented diagnosis. M96.65 is current for fiscal year 2026 and remains in the active CMS ICD-10-CM code set published by the National Center for Health Statistics.

Which HCC does M96.65 map to under V28?

M96.65 does not map to a CMS-HCC V28 payment category. Check the current CMS-HCC V28 model file for payment year 2026 rather than an older V24 tip sheet.

What does M96.65 pay in RAF?

M96.65 has no separately stated V28 community RAF weight. If it is not a V28 payment HCC, it adds nothing to a community RAF score.

What is the V28 vs V24 difference for M96.65?

CMS phased in the V28 risk adjustment model over payment years 2024 (33%), 2025 (67%), and 2026 (100%), replacing V24. V28 consolidates HCC categories, removes some lower-acuity conditions, and recalibrates RAF weights across the entire model. M96.65 was a payment HCC under V24 (Complications of Specified Implanted Device or Graft) but the V28 recalibration removed it from the risk adjustment model. Both models can still appear in legacy data and in payer-specific lookback periods.

What documentation supports M96.65?

This code does not differentiate by laterality since the pelvis is a midline structure Document the relationship between the original orthopedic procedure and the subsequent pelvic fracture to support medical necessity Because M96.65 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. See the MEAT criteria checklist at /meat-criteria for what Monitor, Evaluate, Assess, or Treat looks like in a note. MEAT is generic documentation evidence, not a payer-specific rule.

2026 ICD-10-CM M96.65: Fracture of pelvis

M96.65 is not a CMS-HCC payment code. MEAT criteria · RAF calculator · free HCC coding tools

ICD-10-CM Code View

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Code lookupM96.65Effective periodFY2026 Apr Update (Apr 1-Sep 30)

FY 2026 Apr update / Diseases of the musculoskeletal system and connective tissue (M00-M99) / Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified (M96)

M96.65

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

Fracture of pelvis following insertion of orthopedic implant, joint prosthesis, or bone plate

A fracture of the pelvis that develops as a complication after surgical insertion of an orthopedic implant, joint prosthesis, or bone plate.

Buddy Insight

Pelvic fracture following orthopedic implant insertion represents a severe postoperative complication with major implications for mobility and stability.

CMS-HCC V28

N/A

—

Not risk-adjusted for this model/period.

Not mapped

CMS-HCC V24

Mapped

HCC 176

Complications of Specified Im...

RAF 0.582

ACA/HHS

N/A

—

Not risk-adjusted for this model/period.

Not mapped

ESRD/PACE

Mapped

HCC 176

Complications of Specified Im...

RAF 0.000

RXHCC

N/A

—

Not risk-adjusted for this model/period.

Not mapped

Code Book Path

Official

M96Intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified

M96.6Fracture of bone following insertion of orthopedic implant, joint prosthesis, or bone plate

M96.65Fracture of pelvis following insertion of orthopedic implant, joint prosthesis, or bone plate

Inclusion Terms

Official

Intraoperative fracture of bone during insertion of orthopedic implant, joint prosthesis, or bone plate

Excludes 2

Official

complication of internal orthopedic devices, implants or grafts (T84.-)

Related Child Codes

Official

M96.62Fracture of humerus following insertion of orthopedic implant, joint prosthesis, or bone plate

M96.63Fracture of radius or ulna following insertion of orthopedic implant, joint prosthesis, or bone plate

M96.66Fracture of femur following insertion of orthopedic implant, joint prosthesis, or bone plate

M96.67Fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate

M96.69Fracture of other bone following insertion of orthopedic implant, joint prosthesis, or bone plate

Includes

Official

ICD-10-CM does not list Includes notes for M96.65 in this effective period.

Excludes 1

Official

ICD-10-CM does not list Excludes 1 notes for M96.65 in this effective period.

Code First

Official

ICD-10-CM does not list Code First sequencing instructions for M96.65 in this effective period.

Use Additional

Official

ICD-10-CM does not list Use Additional Code instructions for M96.65 in this effective period.

Code Also

Official

ICD-10-CM does not list Code Also instructions for M96.65 in this effective period.

Buddy Documentation Tip

HCC Buddy guidance

Clear documentation of prior orthopedic implant, prosthesis, or bone plate insertion

Confirmation of pelvic fracture occurring subsequent to implant procedure

Clinical evidence establishing relationship between implant and fracture occurrence

Comprehensive treatment plan for pelvic fracture management

MEAT Support

HCC Buddy guidance

Clear documentation of prior orthopedic implant, prosthesis, or bone plate insertion

Confirmation of pelvic fracture occurring subsequent to implant procedure

Clinical evidence establishing relationship between implant and fracture occurrence

Comprehensive treatment plan for pelvic fracture management

Audit Caution

HCC Buddy guidance

Using routine pelvic fracture codes without establishing implant relationship

Not documenting clear temporal sequence between implant and fracture

Confusing with mechanical device complications rather than bone fracture

Failing to establish causal relationship to prior orthopedic procedure

Common Mistakes

HCC Buddy guidance

S32.9XXA — Fracture of pelvis without implant relationship, initial encounter

T84.048A — Loosening of internal fixation device of pelvis

M96.69 — Fracture of other bone following orthopedic implant insertion

Z96.65 — Presence of pelvic joint implant without complications

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 M96.65 an HCC code?

Yes. M96.65 maps to Complications of Specified Implanted Device or Graft under the V24 model but is not retained in V28.

Code: M96.65
Description: Fracture of pelvis following insertion of orthopedic implant, joint prosthesis, or bone plate
HCC (V28): No CMS-HCC V28 mapping
RAF: —
Billable: Yes
Payment year: 2026

HCC Category Mapping

V24HCC 176, Complications of Specified Implanted Device or Graft

0.582

ESRDHCC 176, Complications of Specified Implanted Device or Graft

0.000

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 M96.65 in the Code Book — tabular path, V28 RAF, and MEAT checklist →

MEAT Criteria for M96.65

For M96.65 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 M96.65 during that encounter, not just copy-forwarded from a problem list.

Coder workflow notes

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What This Code Means

M96.65 is the ICD-10-CM diagnosis code for fracture of pelvis following insertion of orthopedic implant, joint prosthesis, or bone plate. A fracture of the pelvis that develops as a complication after surgical insertion of an orthopedic implant, joint prosthesis, or bone plate. M96.65 sits in the ICD-10-CM chapter for diseases of the musculoskeletal system and connective tissue (m00-m99), within the section covering intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified (m96).

Under the older CMS-HCC V24 model, M96.65 maps to Complications of Specified Implanted Device or Graft (HCC 176) with a community, non-dual, aged base RAF weight of 0.582. 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 does not differentiate by laterality since the pelvis is a midline structure. Because M96.65 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 M96.65 sourced directly from the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.

Coding Tips

•This code does not differentiate by laterality since the pelvis is a midline structure
•Document the relationship between the original orthopedic procedure and the subsequent pelvic fracture to support medical necessity

Clinical Significance

Pelvic fracture following orthopedic implant insertion represents a severe postoperative complication with major implications for mobility and stability. This diagnosis significantly impacts risk adjustment due to the critical nature of pelvic integrity for weight-bearing and the complex surgical management required.

Documentation Requirements

✓Clear documentation of prior orthopedic implant, prosthesis, or bone plate insertion
✓Confirmation of pelvic fracture occurring subsequent to implant procedure
✓Clinical evidence establishing relationship between implant and fracture occurrence
✓Comprehensive treatment plan for pelvic fracture management
✓Assessment of implant stability and potential need for revision surgery
✓Evaluation of weight-bearing status and mobility limitations
✓Documentation excluding external trauma as primary cause
✓Provider statement confirming complication relationship to orthopedic procedure