I82.542
BillableChronic embolism and thrombosis of left tibial vein
HCC Category Mapping
What This Code Means
A blood clot that has formed and persists in the left tibial vein (vein in the lower leg on the left side).
Coding Tips
- •The '2' in the fifth position indicates left-sided involvement; verify documentation clearly states left tibial vein.
- •Distinguish between tibial and peroneal vein thrombosis, as they are coded separately.
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 left-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