I82.541
BillableChronic embolism and thrombosis of right tibial vein
HCC Category Mapping
What This Code Means
A blood clot that has formed and persists in the right tibial vein (vein in the lower leg on the right side).
Coding Tips
- •The '1' in the fifth position indicates right-sided involvement; ensure documentation specifies right tibial vein.
- •Tibial vein thrombosis is a lower extremity deep vein thrombosis and should be documented with clear laterality.
Clinical Significance
Chronic tibial vein thrombosis represents a persistent deep vein thrombosis in the distal lower extremity venous system. Although distal deep vein thrombosis has traditionally been considered lower risk than proximal deep vein thrombosis, chronic tibial vein thrombosis can cause significant post-thrombotic symptoms and may propagate proximally. This diagnosis is relevant for risk adjustment as it demonstrates ongoing vascular disease requiring continued monitoring and treatment.
Documentation Requirements
- ✓Provider documentation explicitly stating 'chronic' deep vein thrombosis (not assumed from duration of treatment)
- ✓Clinical evidence supporting the diagnosis such as duplex ultrasound, venography, or other imaging results
- ✓Specific vein location documented (e.g., tibial)
- ✓Documentation confirming right-sided laterality
- ✓Current treatment plan including anticoagulation therapy and duration
- ✓Assessment and monitoring notes demonstrating the condition is being actively managed
- ✓Documentation of chronicity such as 'chronic,' 'old,' 'long-standing,' or history of prior acute deep vein thrombosis that has transitioned to chronic status