I82.549
BillableChronic embolism and thrombosis of unspecified tibial vein
HCC Category Mapping
V28HCC 267 — Vascular Disease
0.356V24HCC 108 — Vascular Disease
0.297ESRDHCC 108 — Vascular Disease
0.000RxHCCHCC 215 — Pulmonary Embolism and Other Vascular Disease
0.000What This Code Means
A blood clot that has formed and persists in a tibial vein (vein in the lower leg), with the specific side not specified.
Coding Tips
- •Use this code only when the side of the tibial vein thrombosis is not documented; query provider if laterality can be determined.
- •Tibial veins are important deep veins in the lower extremity, so documentation of laterality is clinically important.
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)
- ✓Query provider for laterality (right, left, or bilateral) when not documented
- ✓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
Commonly Confused Codes
I82.449 — Acute embolism and thrombosis of tibial vein; confirm documentation explicitly states chronicI82.55- — Chronic embolism and thrombosis of peroneal vein; the peroneal vein runs parallel to the tibial but is a separate vesselI82.53- — Chronic embolism and thrombosis of popliteal vein; the popliteal is more proximal than the tibial veinI82.5Z- — Chronic embolism of unspecified deep veins of distal lower extremity; use the tibial-specific code when documentation specifies the tibial vein
Code Hierarchy
└I82Other venous embolism and thrombosis└I82.5Chronic embolism and thrombosis of deep veins of lower extremity└I82.54Chronic embolism and thrombosis of tibial vein└I82.549Chronic embolism and thrombosis of unspecified tibial vein
└I82.549Chronic embolism and thrombosis of unspecified tibial vein