ICD-10-CM Billable Code

M65.02

Abscess of tendon sheath, upper arm

Clinical Classification Guidelines

Medical Intelligence & Overview

An abscess of the tendon sheath in the upper arm is a localized infection that results in the accumulation of pus within the protective covering surrounding a tendon. This condition often causes pain, swelling, and tenderness, and requires prompt medical attention to prevent complications. Recognizing the symptoms early and understanding the causes can lead to more effective management and recovery.

Causes & Symptoms

Clinical Causes: Bacterial infections entering through cuts or puncture wounds near the tendon Spread of infections from nearby tissues or skin infections Repeated strain or injury to the tendons which can compromise the sheath Invasive medical procedures or injections in the upper arm area Chronic health conditions that impair immune response, such as diabetes

Key Symptoms: Pain and tenderness along the upper arm tendon Swelling and warmth around the affected area Redness of the skin over the tendon sheath Limited range of motion or stiffness in the arm Fever and general feeling of illness in some cases A palpable fluctuant mass indicating pus accumulation

Diagnostic & Treatment

Diagnosis Path: Physical evaluation: checking for swelling, tenderness, redness, and range of motion Ultrasound imaging: to visualize fluid collection and confirm abscess presence Magnetic resonance imaging (MRI): provides detailed images of the soft tissues including tendons and surrounding structures Laboratory tests: blood tests to identify signs of infection and pus culture to determine the causative bacteria

Treatment Protocols: Antibiotic therapy: tailored to the type of bacteria involved, often initiated empirically and then adjusted based on culture results Drainage of the abscess: usually performed via incision and drainage to remove pus and reduce pressure Rest and immobilization of the affected arm to prevent further injury Pain management: use of analgesics to alleviate discomfort Follow-up care: monitoring for signs of recurrent or persistent infection and ensuring proper healing

Reimbursement claims with a date of service on or after October 1, 2015 require the use of ICD-10-CM codes.

Clinical Advice & FAQs

Billing Guidance

Is M65.02 a billable ICD-10 code?
Yes, M65.02 is a specific, billable code that can be used to indicate a diagnosis for reimbursement purposes.

Documentation

How do I report M65.02?
Clinical documentation must specify the nature of Abscess of tendon sheath, upper arm and any associated comorbidities for accurate reporting.

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