D68.61

HCC Category Mapping

What This Code Means

An autoimmune condition where the body produces antibodies that interfere with blood clotting, causing either excessive bleeding or clotting.

Coding Tips

• •Document positive antiphospholipid antibody test results (anticardiolipin, anti-beta-2 glycoprotein, lupus anticoagulant)
• •Link to associated thrombotic or hemorrhagic events; this condition often coexists with lupus (SLE)

Clinical Significance

Antiphospholipid syndrome is an acquired systemic autoimmune thrombophilia characterized by vascular thrombosis (arterial or venous) and/or pregnancy morbidity in the presence of persistent antiphospholipid antibodies. It may be primary or secondary to systemic lupus erythematosus. Catastrophic antiphospholipid syndrome, involving multi-organ thrombosis, carries high mortality.

Documentation Requirements

• ✓Document positive antiphospholipid antibodies on two occasions at least 12 weeks apart (anticardiolipin IgG/IgM, anti-beta2 glycoprotein I IgG/IgM, or lupus anticoagulant), clinical criteria met (vascular thrombosis or pregnancy morbidity), and whether the condition is primary or secondary.
• ✓Record current anticoagulation regimen and target INR.

Commonly Confused Codes