I82.5Z1
BillableChronic embolism and thrombosis of unspecified deep veins of right distal lower extremity
HCC Category Mapping
What This Code Means
A chronic blood clot in the deep veins of the lower leg or calf area on the right side of the body.
Coding Tips
- •The 'Z' designator indicates distal location (below the knee); distinguish from proximal codes (Y)
- •Verify documentation specifies distal location to avoid miscoding as proximal thrombosis
Clinical Significance
Chronic deep vein thrombosis of the distal lower extremity (unspecified) indicates a long-standing thrombus that has organized within the venous system, often leading to post-thrombotic syndrome with chronic swelling, pain, and skin changes. This condition requires ongoing anticoagulation management and monitoring for recurrent thromboembolism and venous insufficiency. Accurate capture of chronic deep vein thrombosis is essential for risk adjustment as it reflects persistent vascular disease burden.
Documentation Requirements
- ✓Provider documentation explicitly stating 'chronic' deep vein thrombosis (not assumed from duration of treatment)
- ✓Clinical evidence supporting the diagnosis such as duplex ultrasound, venography, or other imaging results
- ✓Query provider for specific vein location when possible
- ✓Documentation confirming right-sided laterality
- ✓Current treatment plan including anticoagulation therapy and duration
- ✓Assessment and monitoring notes demonstrating the condition is being actively managed
- ✓Documentation of chronicity such as 'chronic,' 'old,' 'long-standing,' or history of prior acute deep vein thrombosis that has transitioned to chronic status