I82.A23

HCC Category Mapping

What This Code Means

Blood clots that have formed and persist in both the right and left axillary veins (the main veins in both upper arms).

Coding Tips

• •Use this code only when documentation clearly indicates bilateral involvement of both axillary veins
• •Do not use this code if only one side is affected; use the appropriate unilateral code instead

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 (bilateral) — 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