I82.A19

HCC Category Mapping

What This Code Means

A blood clot that suddenly forms in an axillary vein, but the specific arm (left, right, or both) is not documented.

Coding Tips

• •Use this code only when laterality cannot be determined from medical documentation
• •Query the provider to obtain specific laterality information for more accurate coding

Clinical Significance

Acute axillary vein thrombosis represents a significant vascular event that can lead to pulmonary embolism, post-thrombotic syndrome, and recurrent venous thromboembolism. This diagnosis is critical for risk adjustment as it reflects active vascular disease requiring anticoagulation therapy, monitoring, and potentially invasive interventions. Accurate capture ensures appropriate resource allocation for ongoing management and complication prevention.

Documentation Requirements

• ✓Provider documentation explicitly stating acute embolism or thrombosis of the axillary vein
• ✓Laterality must be documented (unspecified side) — do not assume from context
• ✓Clinical findings supporting the diagnosis (e.g., swelling, pain, imaging results such as duplex ultrasound or CT venography)
• ✓Current treatment plan including anticoagulation therapy type, duration, and monitoring parameters
• ✓Date of onset or timeframe establishing the acute nature of the condition
• ✓Any precipitating factors (central line placement, surgery, malignancy, hypercoagulable state)

Commonly Confused Codes