I82.4Y9
BillableAcute embolism and thrombosis of unspecified deep veins of unspecified proximal 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 blood clot that suddenly forms in an unspecified deep vein of the upper leg area, but the specific leg is not documented.
Coding Tips
- •Use only when both laterality and specific vein are unknown
- •Attempt to query provider for more specific documentation
Clinical Significance
Acute deep vein thrombosis of the proximal lower extremity involves clots in the femoral, popliteal, or iliac veins and carries the highest risk of pulmonary embolism. Proximal deep vein thrombosis requires aggressive anticoagulation and may necessitate interventional procedures such as catheter-directed thrombolysis. This diagnosis significantly impacts risk adjustment due to the high acuity and intensive management requirements.
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
I82.4Z1-I82.4Z9 — Acute DVT of unspecified deep veins of distal lower extremity; distal is below the kneeI82.411-I82.419 — Femoral vein thrombosis; use when specific proximal vein is identified as femoralI82.431-I82.439 — Popliteal vein thrombosis; use when specific proximal vein is identified as poplitealI82.401-I82.409 — Acute DVT of unspecified deep veins without proximal/distal distinctionI82.5Y1-I82.5Y9 — Chronic DVT of proximal lower extremity; verify acute vs. chronic status
Code Hierarchy
└I82Other venous embolism and thrombosis└I82.4Acute embolism and thrombosis of deep veins of lower extremity└I82.4YAcute embolism and thrombosis of unspecified deep veins of proximal lower extremity└I82.4Y9Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity
└I82.4Y9Acute embolism and thrombosis of unspecified deep veins of unspecified proximal lower extremity