I82.A21

HCC Category Mapping

What This Code Means

A blood clot that has formed and persists in the right axillary vein (the main vein in the upper arm), potentially blocking blood flow.

Coding Tips

• •Verify documentation specifies 'chronic' status and confirms right-sided location to distinguish from acute presentations
• •Ensure the thrombosis or embolism is documented as affecting the axillary vein specifically, not other upper extremity vessels

Clinical Significance

Chronic axillary vein thrombosis indicates a long-standing vascular condition with persistent clot burden, reflecting ongoing risk for post-thrombotic syndrome, recurrent thromboembolism, and venous insufficiency. This diagnosis captures the sustained complexity of the patient's vascular disease and the need for long-term anticoagulation management, which is important for accurate risk adjustment.

Documentation Requirements

• ✓Provider documentation explicitly stating chronic embolism or thrombosis of the axillary vein
• ✓Laterality must be documented (right 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
• ✓Duration or timeline establishing chronicity (e.g., 'long-standing,' 'diagnosed 6 months ago')
• ✓Evidence of ongoing monitoring or follow-up imaging confirming persistent thrombus

Commonly Confused Codes