05Q80ZZ
Repair Axillary Vein, Left to No Qualifier with No Device, Open Approach
Procedural Specifications
| Clinical Axis | Detail Definition |
|---|---|
| Section | 0 Medical and Surgical |
| Body System | 5 Upper Veins |
| Operation | Q Repair |
| Body Part | 8 Axillary Vein, Left |
| Approach | 0 Open |
| Device | Z No Device |
| Qualifier | Z No Qualifier |
Operation Definition
Restoring, to the extent possible, a body part to its normal anatomic structure and function
Procedure Overview
This family covers surgical repair of the veins that drain the arms, shoulders, chest wall, and skull, including the subclavian, axillary, brachial, basilic, cephalic, hand, azygos, hemiazygos, innominate, and intracranial veins. Repair is used when a vein has been cut, torn, punctured, or has developed a leak or fistula that needs to be closed by suturing or other direct means, and no other, more specific procedure (like replacing the vein with a graft or widening it with a stent) applies. Typical scenarios include a vein injured during trauma, a laceration from a misplaced central line or dialysis catheter, or bleeding discovered during an unrelated operation.
Because these veins carry blood back toward the heart at relatively low pressure, many injuries can be managed with direct suture repair rather than a graft, which is why this family exists as a distinct, catch-all restorative option. Patients undergoing this procedure are typically being treated for an acute injury or a complication of another medical intervention rather than a planned elective condition.
Anatomy & Axis Detail
Axillary Vein, Left
The left axillary vein follows the same course as the right, extending from the teres major border to the outer edge of the first rib and lying medial to the axillary artery within the neurovascular bundle of the axilla. Repair is undertaken for lacerations occurring during breast or axillary surgery, penetrating trauma, or complications of central line and port placement, as well as venous injury from repetitive overhead activity that produces effort-related thrombosis. Given its proximity to the brachial plexus cords and the risk of postoperative lymphedema when the axilla is disturbed, the approach favors precise, limited dissection, and the operative note should specify laterality clearly since axillary vein pathology is often unilateral and activity related.
Approach: Open
Open approach means the surgeon cuts through skin, mucous membrane, or other tissue layers to physically expose the target site to view before performing the procedure. It gives direct visualization and hands-on access, distinguishing it from Percutaneous approaches where instruments pass through a small puncture without exposing the site. Open is typical for procedures needing wide access, such as most laparotomies.
Coding & Documentation
Repair is assigned only when documentation shows the surgeon restored the vein's own tissue to its normal structure - for example, "venorrhaphy," "suture repair of laceration," or "closure of iatrogenic venous injury" - without introducing graft material or performing a more specific root operation. The operative note should identify the exact vein involved (since Upper Veins has separate body part values for each named vessel) and describe the technique used to close the defect.
The most common coding error is defaulting to Repair whenever a vein procedure doesn't obviously fit elsewhere, when in fact a more specific root operation is required if the physician actually excised tissue, controlled bleeding through ligation, or patched the vessel with graft material. Coders also miscode the body part by using a generic "upper vein" value instead of the specific named vessel documented, or they miss that Repair is inappropriate when the vein was ligated and divided rather than reconstructed.