I80.201
BillablePhlebitis and thrombophlebitis of unspecified deep vessels of right lower extremity
HCC Category Mapping
What This Code Means
Inflammation and blood clot formation in an unspecified deep vein of the right leg.
Coding Tips
- •This code is used when a deep vein thrombosis is documented but the specific vein is not identified
- •Attempt to obtain more specific documentation of which deep vein is affected (popliteal, tibial, peroneal, etc.)
Clinical Significance
Phlebitis and thrombophlebitis of unspecified deep vessels of the right lower extremity indicates deep vein thrombosis without specification of the exact vein involved. Deep vein thrombosis is a significant condition carrying risk of pulmonary embolism and post-thrombotic syndrome. While this code captures the deep vein thrombosis, providers should be queried for the specific vein (femoral, popliteal, tibial) to enable more precise coding.
Documentation Requirements
- ✓Imaging confirmation of deep vein thrombosis (duplex ultrasound or CT venography)
- ✓Laterality — right side documented
- ✓Query provider for specific deep vein involvement when possible
- ✓Acuity — acute, subacute, or chronic thrombosis
- ✓Evaluation for pulmonary embolism
- ✓Anticoagulation plan with agent, dose, and planned duration
- ✓Risk factor assessment including malignancy screening if appropriate