I82.5Z3
BillableChronic embolism and thrombosis of unspecified deep veins of distal lower extremity, bilateral
HCC Category Mapping
What This Code Means
A chronic blood clot affecting the deep veins of the lower leg or calf area on both sides of the body.
Coding Tips
- •Bilateral distal DVT is less common than unilateral; verify both legs are documented with clots
- •The '3' suffix indicates both sides; ensure documentation supports bilateral involvement
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 bilateral involvement (both extremities affected)
- ✓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