I82.629
BillableAcute embolism and thrombosis of deep veins of unspecified upper extremity
HCC Category Mapping
What This Code Means
A blood clot that suddenly forms in the deep veins of an arm when the specific side is not documented or specified.
Coding Tips
- •Use only when laterality is not specified in the medical record
- •Attempt to query provider for clarification on right versus left involvement
Clinical Significance
Acute deep vein thrombosis of the upper extremity is a significant vascular event that carries risk of pulmonary embolism and requires immediate anticoagulation therapy. Upper extremity deep vein thrombosis is increasingly recognized, often associated with central venous catheters, pacemaker leads, or thoracic outlet syndrome. This diagnosis captures important vascular disease burden for risk adjustment and signals the need for ongoing monitoring and treatment.
Documentation Requirements
- ✓Provider documentation explicitly stating 'acute' 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., upper extremity)
- ✓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 any predisposing factors such as central venous catheter, pacemaker, or thoracic outlet syndrome