I82.413

HCC Category Mapping

What This Code Means

A blood clot that suddenly forms in both thigh veins (femoral veins), blocking blood flow in both legs.

Coding Tips

• •Use this code only when documentation explicitly states bilateral involvement
• •Do not use if only one side is affected; use laterality-specific codes instead

Clinical Significance

Acute thrombosis of the femoral vein, a major proximal deep vein in the thigh, represents a high-risk deep vein thrombosis with significant potential for pulmonary embolism. Proximal deep vein thrombosis carries greater morbidity than distal clots and typically requires aggressive anticoagulation, potential catheter-directed thrombolysis, and close monitoring. Capturing this diagnosis accurately reflects the acute care needs and ongoing vascular disease risk of these patients.

Documentation Requirements

• ✓Clinical diagnosis of venous thrombosis or thrombophlebitis clearly documented by the treating provider
• ✓Diagnostic confirmation via duplex ultrasonography, CT venography, MR venography, or venography with imaging findings described
• ✓Current treatment plan including anticoagulation regimen with specific medication, dose, and duration
• ✓Documentation of acute onset with date of symptom onset or diagnosis establishing the acute nature
• ✓Explicit documentation that both lower extremities are affected
• ✓Assessment of risk factors (immobility, recent surgery, malignancy, hypercoagulable state, oral contraceptive use)

Commonly Confused Codes