I80.203
BillablePhlebitis and thrombophlebitis of unspecified deep vessels of lower extremities, bilateral
HCC Category Mapping
What This Code Means
Inflammation and blood clot formation in unspecified deep veins affecting both legs.
Coding Tips
- •Bilateral deep vein thrombosis is a serious condition; ensure documentation supports bilateral involvement
- •Attempt to identify the specific deep veins involved in each leg for greater specificity
Clinical Significance
Phlebitis and thrombophlebitis of unspecified deep vessels of the bilateral 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 — bilateral 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