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ICD-10 Guide
ICD-10 CodesM61.41

M61.41

Billable

Other calcification of muscle, shoulder

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

Code Description

ICD-10 M61.41 is a billable code used to indicate a diagnosis of other calcification of muscle, shoulder.

Key Diagnostic Point:

M61.41 refers to the condition characterized by abnormal calcification in the muscles of the shoulder region. This condition can arise from various underlying causes, including trauma, inflammation, or metabolic disorders. Calcification in muscle tissue can lead to stiffness, pain, and reduced range of motion, significantly impacting a patient's quality of life. The calcification may be associated with myositis, a condition where muscle inflammation occurs, leading to muscle weakness and discomfort. Patients may present with symptoms such as localized pain, swelling, and tenderness in the shoulder area, which can mimic other shoulder disorders. Diagnosis typically involves imaging studies, such as X-rays or MRI, to visualize the calcified areas and assess the extent of muscle involvement. Treatment options may include physical therapy, pain management, and in some cases, surgical intervention to remove the calcified tissue. Understanding the nuances of this condition is essential for accurate coding and effective patient management.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between types of calcification (e.g., traumatic vs. metabolic)
  • Need for precise documentation of symptoms and imaging findings
  • Potential overlap with other shoulder conditions (e.g., rotator cuff injuries)
  • Variability in treatment approaches based on underlying causes

Audit Risk Factors

  • Inadequate documentation of the cause of calcification
  • Failure to document associated symptoms or functional limitations
  • Misclassification of calcification type
  • Lack of imaging reports to support the diagnosis

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

Detailed clinical notes, imaging results, and treatment plans must be documented.

Common Clinical Scenarios

Patients presenting with shoulder pain and limited range of motion due to calcification.

Billing Considerations

Orthopedic specialists should ensure that all relevant imaging studies are included in the documentation to support the diagnosis.

Rheumatology

Documentation Requirements

Comprehensive history of autoimmune conditions, lab results, and treatment responses.

Common Clinical Scenarios

Patients with myositis or other inflammatory conditions presenting with calcification.

Billing Considerations

Rheumatologists should document any systemic symptoms that may indicate an underlying rheumatologic condition.

Coding Guidelines

Inclusion Criteria

Use M61.41 When
  • According to ICD
  • 10 guidelines, M61
  • 41 should be used when there is clear documentation of calcification in the shoulder muscles
  • It is essential to include the cause of calcification, whether it is due to trauma, inflammation, or other underlying conditions

Exclusion Criteria

Do NOT use M61.41 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 a patient with shoulder calcification requires aspiration of fluid or injection for pain relief.

Documentation Requirements

Document the indication for the procedure and any imaging findings.

Specialty Considerations

Orthopedic specialists should ensure that the procedure is justified based on the patient's symptoms.

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 M61.41, improving the accuracy of patient records and facilitating better treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like M61.41, improving the accuracy of patient records and facilitating better treatment planning.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like M61.41, improving the accuracy of patient records and facilitating better treatment planning.

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 are the common symptoms associated with M61.41?

Common symptoms include shoulder pain, stiffness, and limited range of motion, often accompanied by tenderness in the affected area.

How is M61.41 diagnosed?

Diagnosis typically involves a combination of clinical evaluation and imaging studies, such as X-rays or MRI, to confirm the presence of calcification in the shoulder muscles.