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ICD-10 Guide
ICD-10 CodesM61.049

M61.049

Billable

Myositis ossificans traumatica, unspecified hand

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/17/2025

Code Description

ICD-10 M61.049 is a billable code used to indicate a diagnosis of myositis ossificans traumatica, unspecified hand.

Key Diagnostic Point:

Myositis ossificans traumatica is a condition characterized by the abnormal formation of bone tissue within muscle or connective tissue following trauma. This condition typically arises after an injury, such as a fracture or severe contusion, leading to inflammation and subsequent ossification in the affected area. In the case of unspecified hand involvement, the condition may manifest as pain, swelling, and reduced range of motion in the hand due to the formation of heterotopic bone. Patients may experience muscle weakness and functional impairment as the ossification progresses. Diagnosis is often confirmed through imaging studies, such as X-rays or MRI, which reveal the presence of calcified tissue within the muscle. Treatment may include physical therapy, pain management, and in some cases, surgical intervention to remove the ossified tissue if it significantly impacts function. Understanding the nuances of myositis ossificans is crucial for accurate coding and effective patient management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and severity of symptoms
  • Need for precise documentation of trauma history
  • Differentiation from other musculoskeletal conditions
  • Potential for co-occurring conditions affecting the hand

Audit Risk Factors

  • Inadequate documentation of the traumatic event
  • Failure to specify laterality when applicable
  • Misinterpretation of imaging results
  • Lack of follow-up documentation on treatment outcomes

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed history of trauma, imaging results, and treatment plans.

Common Clinical Scenarios

Post-traumatic evaluation of hand injuries, surgical intervention for ossification.

Billing Considerations

Ensure clear documentation of the mechanism of injury and any associated conditions.

Physical Medicine and Rehabilitation

Documentation Requirements

Functional assessments, therapy progress notes, and patient-reported outcomes.

Common Clinical Scenarios

Rehabilitation following trauma, management of pain and mobility issues.

Billing Considerations

Document the impact of myositis ossificans on functional abilities and therapy goals.

Coding Guidelines

Inclusion Criteria

Use M61.049 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the condition's onset, treatment, and any associated complications
  • Include specific details about the trauma and its impact on muscle function

Exclusion Criteria

Do NOT use M61.049 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

20610CPT Code

Arthrocentesis, aspiration and/or injection into a major joint or bursa

Clinical Scenario

Used when joint aspiration is needed due to swelling from myositis ossificans.

Documentation Requirements

Document the reason for aspiration and findings during the procedure.

Specialty Considerations

Orthopedic specialists should ensure clear documentation of joint involvement.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like myositis ossificans, improving the accuracy of patient records and billing. This specificity aids in better tracking of treatment outcomes and resource allocation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like myositis ossificans, improving the accuracy of patient records and billing. This specificity aids in better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

billing. This specificity aids in better tracking of treatment outcomes and resource allocation.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is myositis ossificans?

Myositis ossificans is a condition where bone tissue forms inside muscle or connective tissue, usually following trauma. It can lead to pain, swelling, and reduced mobility.

How is myositis ossificans diagnosed?

Diagnosis typically involves a clinical evaluation and imaging studies, such as X-rays or MRI, to identify the presence of ossified tissue.

What are the treatment options for myositis ossificans?

Treatment may include physical therapy, pain management, and in some cases, surgical removal of the ossified tissue if it significantly affects function.