I82.409
BillableAcute embolism and thrombosis of unspecified deep veins of unspecified lower extremity
HCC Category Mapping
V28HCC 267 — Vascular Disease
0.356V24HCC 108 — Vascular Disease
0.297ESRDHCC 108 — Vascular Disease
0.000RxHCCHCC 215 — Pulmonary Embolism and Other Vascular Disease
0.000What This Code Means
A sudden blood clot in the deep veins of the leg when the specific leg side is not documented or specified.
Coding Tips
- •Use this code only when laterality cannot be determined from documentation; query provider if possible
- •Ensure acute status is confirmed and document any available information about risk factors or symptoms
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
- ✓Laterality documentation should be sought; if unavailable, document the reason laterality cannot be determined
- ✓Assessment of risk factors (immobility, recent surgery, malignancy, hypercoagulable state, oral contraceptive use)
Commonly Confused Codes
I82.411-I82.419 — Femoral vein thrombosis; use when specific vein is identified as femoralI82.431-I82.439 — Popliteal vein thrombosis; use when specific vein is identified as poplitealI82.441-I82.449 — Tibial vein thrombosis; use when specific vein is identified as tibialI80.20-I80.29 — Phlebitis and thrombophlebitis of deep vessels; use when inflammatory component is presentI82.401-I82.409 — Acute DVT of unspecified deep veins; less specific than other specified codes
Code Hierarchy
└I82Other venous embolism and thrombosis└I82.4Acute embolism and thrombosis of deep veins of lower extremity└I82.40Acute embolism and thrombosis of unspecified deep veins of lower extremity└I82.409Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity
└I82.409Acute embolism and thrombosis of unspecified deep veins of unspecified lower extremity