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ICD-10 Guide
ICD-10 CodesM61.069

M61.069

Billable

Myositis ossificans traumatica, unspecified lower leg

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

Code Description

ICD-10 M61.069 is a billable code used to indicate a diagnosis of myositis ossificans traumatica, unspecified 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 ossification in the affected area. In the case of the unspecified lower leg, the condition may involve the muscles of the calf or surrounding structures. Patients may present with localized pain, swelling, and reduced range of motion in the affected leg. The ossification can lead to muscle weakness and functional impairment, complicating rehabilitation efforts. Diagnosis is often confirmed through imaging studies, such as X-rays or MRI, which reveal the presence of calcified tissue. Treatment may include physical therapy, pain management, and in some cases, surgical intervention to remove the ossified tissue if it significantly impacts mobility or quality of life. Understanding the underlying muscle disorders and neuromuscular conditions is crucial for effective management and coding of this condition.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between myositis ossificans and other types of muscle injuries.
  • Understanding the specific location and extent of ossification.
  • Documenting the trauma history accurately to support the diagnosis.
  • Identifying associated muscle weakness and functional limitations.

Audit Risk Factors

  • Inadequate documentation of the traumatic event leading to myositis ossificans.
  • Failure to specify the affected muscle group or location.
  • Lack of imaging studies to support the diagnosis.
  • Inconsistent coding of related conditions or complications.

Specialty Focus

Medical Specialties

Orthopedics

Documentation Requirements

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

Common Clinical Scenarios

Post-traumatic cases following fractures or sports injuries.

Billing Considerations

Ensure clarity on the extent of ossification and its impact on mobility.

Physical Medicine and Rehabilitation

Documentation Requirements

Functional assessments, rehabilitation goals, and progress notes.

Common Clinical Scenarios

Patients undergoing rehabilitation post-injury with myositis ossificans.

Billing Considerations

Focus on documenting muscle weakness and functional limitations for accurate coding.

Coding Guidelines

Inclusion Criteria

Use M61.069 When
  • Follow the official ICD
  • CM coding guidelines, ensuring accurate documentation of the traumatic event and the specific muscle group affected
  • Include any relevant imaging studies and treatment plans to support the diagnosis

Exclusion Criteria

Do NOT use M61.069 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 associated swelling.

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 myositis ossificans, improving the accuracy of data collection and reimbursement processes. 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 myositis ossificans, improving the accuracy of data collection and reimbursement processes. This specificity aids in better tracking of treatment outcomes and resource allocation.

Reimbursement & Billing Impact

reimbursement processes. 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 traumatica?

Myositis ossificans traumatica is a condition where bone tissue forms within muscle or connective tissue following trauma, leading to pain and functional impairment.

How is myositis ossificans diagnosed?

Diagnosis is typically made through clinical evaluation and imaging studies, such as X-rays or MRI, which reveal calcified lesions in the affected muscle.

What are the treatment options for myositis ossificans?

Treatment may include physical therapy, pain management, and surgical intervention if the ossification significantly affects mobility.