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ICD-10 Guide
ICD-10 CodesM61.061

M61.061

Billable

Myositis ossificans traumatica, right lower leg

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

Code Description

ICD-10 M61.061 is a billable code used to indicate a diagnosis of myositis ossificans traumatica, right lower leg.

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 calcification of the affected muscle. In the case of the right lower leg, the muscle groups involved may include the gastrocnemius, soleus, or other surrounding musculature. Patients may present with localized swelling, pain, and reduced range of motion in the affected area. Diagnosis is often confirmed through imaging studies, such as X-rays or MRI, which reveal the presence of heterotopic ossification. Treatment may involve physical therapy, pain management, and in some cases, surgical intervention to remove the ossified tissue if it leads to significant functional impairment. Understanding the underlying mechanisms of myositis ossificans is crucial for effective management and rehabilitation of affected patients.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires knowledge of specific muscle anatomy and injury mechanisms.
  • Differentiation from other types of myositis and ossification disorders.
  • Need for accurate documentation of trauma history.
  • Potential for overlapping symptoms with other neuromuscular conditions.

Audit Risk Factors

  • Inadequate documentation of the traumatic event leading to the condition.
  • Failure to specify the exact muscle group affected.
  • Misclassification of the type of myositis.
  • Lack of imaging studies to support the diagnosis.

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed history of the injury, imaging results, and treatment plans.

Common Clinical Scenarios

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

Billing Considerations

Need for clear documentation of the mechanism of injury and follow-up assessments.

Physical Medicine and Rehabilitation

Documentation Requirements

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

Common Clinical Scenarios

Rehabilitation following surgical removal of ossified tissue, management of pain and mobility.

Billing Considerations

Focus on functional improvement and long-term outcomes.

Coding Guidelines

Inclusion Criteria

Use M61.061 When
  • According to ICD
  • 10 guidelines, M61
  • 061 should be used when there is clear documentation of myositis ossificans resulting from trauma specifically in the right lower leg
  • It is important to ensure that the diagnosis is supported by imaging and clinical findings

Exclusion Criteria

Do NOT use M61.061 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.

Specialty Considerations

Orthopedic specialists may frequently perform this procedure.

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 data collection and reimbursement processes.

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 data collection and reimbursement processes.

Reimbursement & Billing Impact

reimbursement processes.

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 traumatica?

Myositis ossificans traumatica is a condition where bone tissue forms in muscle or connective tissue following trauma, leading to pain and reduced mobility.