I82.403

HCC Category Mapping

What This Code Means

A blood clot has suddenly formed in the deep veins of both legs. This is a serious condition where blood flow is blocked in the major veins beneath the skin on both sides of the body.

Coding Tips

• •Verify documentation specifies 'bilateral' involvement of both lower extremities before assigning this code; if only one leg is affected, use a more specific unilateral code instead
• •Ensure the clinical record documents this as 'acute' rather than chronic; acute indicates sudden onset within the current episode of care

Clinical Significance

Acute deep vein thrombosis of the lower extremity is a serious vascular condition carrying risk of pulmonary embolism if the clot dislodges and travels to the lungs. These patients require urgent anticoagulation therapy and ongoing monitoring to prevent clot extension and recurrence. Accurate coding ensures proper risk adjustment reflecting the acute care needs and chronic vascular disease burden.

Documentation Requirements

• ✓Clinical diagnosis of venous thrombosis or thrombophlebitis clearly documented by the treating provider
• ✓Diagnostic confirmation via duplex ultrasonography, CT venography, MR venography, or venography with imaging findings described
• ✓Current treatment plan including anticoagulation regimen with specific medication, dose, and duration
• ✓Documentation of acute onset with date of symptom onset or diagnosis establishing the acute nature
• ✓Explicit documentation that both lower extremities are affected
• ✓Assessment of risk factors (immobility, recent surgery, malignancy, hypercoagulable state, oral contraceptive use)

Commonly Confused Codes