I82.499
BillableAcute embolism and thrombosis of other specified deep vein of unspecified lower extremity
HCC Category Mapping
What This Code Means
A blood clot that suddenly forms in a deep vein of the leg, but the specific leg is not documented.
Coding Tips
- •Use only when laterality cannot be determined from medical record
- •Query provider if possible to obtain specific leg location for more precise coding
Clinical Significance
Acute deep vein thrombosis of other specified deep veins of the lower extremity represents a significant vascular event requiring prompt anticoagulation therapy. Deep vein thrombosis carries risk of pulmonary embolism and long-term post-thrombotic syndrome, necessitating ongoing medical management. Accurate coding is essential for risk adjustment as these patients require sustained vascular disease monitoring and treatment.
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)