I80.209
BillablePhlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity
HCC Category Mapping
What This Code Means
Inflammation and blood clot formation in an unspecified deep vein of the lower leg, but it's unclear which leg is affected.
Coding Tips
- •This is a less specific code; query the provider to determine laterality (right, left, or bilateral) for more accurate coding
- •Verify if the deep vein thrombosis is associated with a specific vessel (popliteal, tibial, peroneal, or iliac) to assign a more specific code
Clinical Significance
Phlebitis and thrombophlebitis of unspecified deep vessels of the unspecified 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 — query provider for specific side
- ✓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