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ICD-10 Guide
ICD-10 CodesM61.09

M61.09

Billable

Myositis ossificans traumatica, multiple sites

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

Code Description

ICD-10 M61.09 is a billable code used to indicate a diagnosis of myositis ossificans traumatica, multiple sites.

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 a significant injury, such as fractures, contusions, or surgical procedures, leading to calcification and ossification in the affected muscles. The condition can occur at multiple sites, which complicates both diagnosis and treatment. Patients may present with localized pain, swelling, and reduced range of motion in the affected areas. The ossification can lead to muscle weakness and functional impairment, as the normal muscle tissue is replaced by bone. Diagnosis is often confirmed through imaging studies, such as X-rays or MRI, which reveal the presence of calcified masses within the muscle. Treatment may involve physical therapy, pain management, and in some cases, surgical intervention to remove the ossified tissue. Understanding the nuances of myositis ossificans traumatica is crucial for accurate coding and appropriate management of affected patients.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Requires understanding of trauma-related conditions
  • Differentiation from other types of myositis
  • Multiple site involvement complicates documentation
  • Need for precise imaging documentation

Audit Risk Factors

  • Inadequate documentation of trauma history
  • Failure to specify multiple sites of ossification
  • Lack of imaging studies to support diagnosis
  • Misinterpretation of symptoms as other myositis types

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

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

Common Clinical Scenarios

Post-traumatic ossification following fractures or surgical interventions.

Billing Considerations

Ensure clear documentation of the extent and location of ossification.

Physical Medicine and Rehabilitation

Documentation Requirements

Functional assessments, treatment progress notes, and rehabilitation goals.

Common Clinical Scenarios

Patients undergoing rehabilitation for muscle weakness due to myositis ossificans.

Billing Considerations

Document functional limitations and response to therapy.

Coding Guidelines

Inclusion Criteria

Use M61.09 When
  • Follow official ICD
  • 10 coding guidelines, ensuring accurate documentation of trauma history and multiple sites of ossification
  • Include relevant imaging studies and treatment plans in the medical record

Exclusion Criteria

Do NOT use M61.09 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 treating joint pain associated with myositis ossificans.

Documentation Requirements

Document the reason for aspiration/injection and findings.

Specialty Considerations

Orthopedic specialists should ensure clear linkage between the procedure and diagnosis.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of myositis ossificans, improving the accuracy of diagnoses and treatment plans. It has also facilitated better tracking of conditions related to trauma.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of myositis ossificans, improving the accuracy of diagnoses and treatment plans. It has also facilitated better tracking of conditions related to trauma.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of myositis ossificans, improving the accuracy of diagnoses and treatment plans. It has also facilitated better tracking of conditions related to trauma.

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 the primary cause of myositis ossificans traumatica?

Myositis ossificans traumatica is primarily caused by trauma to the muscle, leading to abnormal bone formation in response to injury.

How is myositis ossificans diagnosed?

Diagnosis is typically made through a combination of patient history, physical examination, and imaging studies such as X-rays or MRI that reveal calcified lesions in the muscle.

What are the treatment options for myositis ossificans?

Treatment may include physical therapy, pain management, and in some cases, surgical intervention to remove the ossified tissue.