I82.4Z1

HCC Category Mapping

What This Code Means

A blood clot has suddenly formed in the deep veins of the right leg below the knee. This is a serious condition that can restrict blood flow and cause swelling, pain, and potentially life-threatening complications if the clot travels to the lungs.

Coding Tips

• •Verify the laterality (right vs. left) and specificity of location (distal vs. proximal) in the documentation before assigning the code, as these details are essential for accurate coding
• •Ensure the thrombosis is documented as acute rather than chronic, and confirm whether the site is truly unspecified or if more specific anatomical detail (such as calf veins) is documented in the medical record

Clinical Significance

Acute deep vein thrombosis of the distal lower extremity involves clots in the tibial, peroneal, or calf muscular veins below the knee. While carrying lower pulmonary embolism risk than proximal clots, distal deep vein thrombosis still requires treatment decisions based on individual risk assessment and may progress proximally if untreated. Accurate capture ensures appropriate risk stratification for patients with vascular disease.

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