I82.5Z2
BillableChronic embolism and thrombosis of unspecified deep veins of left 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 left side of the body.
Coding Tips
- •The 'Z' designator indicates distal location; confirm the clot is below the knee
- •Left-sided distal DVT may have different clinical implications than proximal; ensure accurate laterality documentation
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 left-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