I87.019
BillablePostthrombotic syndrome with ulcer of unspecified lower extremity
HCC Category Mapping
What This Code Means
A condition that develops after a blood clot in the leg, causing an open sore or ulcer on the lower leg when the specific side is not documented or specified.
Coding Tips
- •Use only when laterality cannot be determined from documentation
- •Query provider if possible to determine right, left, or bilateral involvement for more specific coding
Clinical Significance
Postthrombotic syndrome with ulcer of the unspecified 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 (unspecified 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