I74.2

Embolism and thrombosis of arteries of upper extremities

Embolism and thrombosis of the arteries of the upper extremities (I74.2) refers to a partial or complete occlusion of arterial blood flow to the arms. This condition is a clinical emergency known as acute limb ischemia (ALI) when it occurs suddenly. The obstruction typically involves the subclavian, axillary, brachial, radial, or ulnar arteries. Most cases in the upper extremities are embolic in origin, frequently arising from a cardiac source (e.g., atrial fibrillation or valvular disease) or from proximal arterial pathologies such as thoracic outlet syndrome or subclavian artery aneurysms. Thrombosis, on the other hand, usually occurs in the setting of underlying atherosclerosis, trauma, or iatrogenic injury during vascular procedures. Without rapid diagnosis and intervention (such as anticoagulation, embolectomy, or thrombolysis), ischemia can lead to irreversible tissue necrosis, nerve damage, and potentially the loss of the limb.

Clinical Symptoms

Sudden, severe pain in the affected arm or hand
Pallor (pale or mottled skin color)
Pulselessness in the radial, ulnar, or brachial sites
Paresthesia (numbness or 'pins and needles' sensation)
Paralysis or significant motor weakness
Poikilothermia (coldness of the limb relative to the contralateral side)
Slowed or absent capillary refill in the fingers
Visible cyanosis (bluish discoloration) of the digits
Muscle tenderness or rigidity in advanced ischemia

Common Causes

Atrial fibrillation leading to cardiac mural thrombus formation
Thoracic Outlet Syndrome (TOS) causing repetitive arterial compression and post-stenotic dilation
Atherosclerosis with acute plaque rupture and thrombus formation
Subclavian or axillary artery aneurysms with mural thrombus embolization
Iatrogenic injury during arterial catheterization or surgery
Blunt or penetrating trauma to the shoulder or arm
Hypercoagulable states (e.g., Factor V Leiden, Protein C or S deficiency, malignancy)
Vasculitis (e.g., Takayasu arteritis or Giant Cell Arteritis)
Intravenous drug abuse (accidental intra-arterial injection)

Documentation & Coding Tips

Document specific laterality and the exact arterial vessel involved to ensure maximum clinical precision and support medical necessity for imaging.

Example: Patient presents with acute onset of coldness and cyanosis of the right hand. Physical exam reveals absent radial and ulnar pulses. Duplex ultrasonography confirms acute embolism of the right brachial artery at the antecubital fossa. History is significant for permanent atrial fibrillation with an inadequate INR of 1.4. This encounter supports I74.2 for the acute embolism and I48.21 for permanent atrial fibrillation, impacting the HCC 108 risk category.

Billing Focus: Right laterality, brachial artery location, and acute episode of care status.

Distinguish between embolism and thrombosis in the documentation, even though they share the same ICD-10 code, to support the rationale for surgical vs. medical management.

Example: 65-year-old male with known axillary artery aneurysm now presents with acute thrombosis of the left axillary artery. Patient reports sudden onset of paresthesia and weakness in the left arm. Clinical assessment indicates thrombosis secondary to stasis within the aneurysmal sac. This documentation supports the medical necessity for CPT 34101 (embolectomy) and justifies high-complexity medical decision making.

Billing Focus: Identify the underlying cause such as an aneurysm (I72.1) to support surgical intervention codes.

Clearly document the presence or absence of gangrene or skin ulceration, as these require additional codes and significantly increase the risk adjustment weight.

Example: Acute thrombosis of the right radial artery resulting in critical limb ischemia and localized gangrene of the second and third digits. Wound care performed for gangrenous tissue. Documentation includes I74.2 (arterial thrombosis), I96 (gangrene), and L98.491 (non-pressure chronic ulcer of other part of right lower leg - if applicable, or local tissue necrosis).

Billing Focus: Linking the arterial occlusion to the secondary manifestation of gangrene.

Specify the clinical manifestation such as claudication, rest pain, or acute limb ischemia to determine the acuity of the condition.

Example: Patient reports worsening rest pain in the left forearm over the last 48 hours. Evaluation shows chronic atherosclerosis of native arteries of the upper extremities with superimposed acute embolism of the left ulnar artery. The patient requires immediate heparinization and vascular surgical consultation for impending limb loss.

Billing Focus: Acute limb ischemia manifestations to support emergency-level E/M coding.

Identify if the embolism or thrombosis is related to a prosthetic device, graft, or catheter, as these may require T-codes for complications.

Example: Patient with end-stage renal disease on hemodialysis presents with thrombosis of the right brachial artery proximal to the arteriovenous fistula. This is documented as a complication of the vascular access device. Final coding includes T82.868A (Thrombosis due to vascular prosthetic devices, implants and grafts) and I74.2.

Billing Focus: Device-related complications change the primary diagnosis to a T-code in many billing scenarios.

Relevant CPT Codes

99214 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30-39 minutes must be met or exceeded.
Typically used for follow-up of stable thrombosis or management of long-term anticoagulation where systemic risks are addressed.
99204 - Office or other outpatient visit for the evaluation and management of a new patient, which requires a moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45-59 minutes must be met or exceeded.
Initial consultation for symptoms of upper extremity ischemia where multiple diagnostic options and treatment plans (surgical vs medical) are discussed.
99213 - Office or other outpatient visit for the evaluation and management of an established patient, which requires a low level of medical decision making. When using total time on the date of the encounter for code selection, 20-29 minutes must be met or exceeded.
Used for routine monitoring of medication efficacy or wound healing post-thrombosis in a stable patient.
93930 - Duplex scan of upper extremity arteries or arterial grafts; complete bilateral study
Primary diagnostic imaging modality to confirm the presence and location of a thrombus or embolus.
93931 - Duplex scan of upper extremity arteries or arterial grafts; unilateral or limited study
Used when symptoms are localized to a single extremity to confirm I74.2.
34101 - Embolectomy or thrombectomy, with or without catheter; axillary, brachial, innate, subclavian artery, by arm incision
The definitive surgical treatment for acute I74.2 presenting with limb-threatening ischemia.
37184 - Primary percutaneous transluminal mechanical thrombectomy, arterial, including intraprocedural pharmacological thrombolytic injection(s); initial vessel
Minimally invasive alternative to open surgery for treating thrombosis of upper extremity arteries.
37211 - Transcatheter therapy, arterial infusion for thrombolysis other than coronary, any method, including radiological supervision and interpretation, continued treatment on subsequent day; initial day
Used for subacute thrombosis where catheter-directed clot dissolving medication is indicated.
36215 - Selective catheter placement, arterial system; each first order thoracic or brachiocephalic branch, within a vascular family
Necessary procedure to perform diagnostic angiography before intervention for I74.2.
75710 - Angiography, extremity, unilateral, radiological supervision and interpretation
Gold standard for defining arterial anatomy and the exact point of occlusion in I74.2.