I87.011
BillablePostthrombotic syndrome with ulcer of right lower extremity
HCC Category Mapping
What This Code Means
Chronic pain, swelling, and skin changes in the right leg following a previous blood clot, with an open sore or ulcer.
Coding Tips
- •When ulcer is present, additional codes for ulcer severity and site may be required; verify complete documentation
- •The presence of ulceration indicates more severe disease and may affect treatment planning and reimbursement
Clinical Significance
Postthrombotic syndrome with ulcer of the right lower extremity represents a chronic sequela of deep vein thrombosis where permanent venous valve damage leads to chronic venous hypertension, causing skin breakdown and ulceration. This condition requires ongoing wound care, compression therapy, and close vascular monitoring, significantly increasing healthcare utilization. The presence of ulceration marks advanced disease that substantially impacts the patient's functional status and quality of life.
Documentation Requirements
- ✓History of deep vein thrombosis documented or referenced
- ✓Diagnosis of postthrombotic syndrome explicitly stated (not just chronic venous insufficiency)
- ✓Laterality documented (right lower extremity)
- ✓Ulcer presence and characteristics described (size, location, depth, drainage)
- ✓Signs of chronic venous changes (hyperpigmentation, lipodermatosclerosis, edema)
- ✓Current wound management and compression therapy plan
- ✓Assessment of venous reflux or obstruction if available