I87.031

Billable

Postthrombotic syndrome with ulcer and inflammation of right lower extremity

HCC Category Mapping

V28HCC 383 — Diabetic Skin Ulcer and Severe Skin Conditions

0.517

V24HCC 107 — Vascular Disease with Complications

0.450

ESRDHCC 107 — Vascular Disease with Complications

0.000

What This Code Means

A condition that develops after a blood clot in the leg, causing both an open sore and swelling/redness on the right lower leg.

Coding Tips

•Use only when BOTH ulcer AND inflammation are present on the right side
•Document both components clearly to justify this more severe code selection

Clinical Significance

Postthrombotic syndrome with both ulcer and inflammation of the right lower extremity represents the most severe manifestation of chronic post-deep vein thrombosis sequelae. The combination of ulceration and active inflammation indicates ongoing tissue damage, impaired wound healing, and elevated infection risk. This condition demands intensive wound management, compression therapy, and possibly antibiotic treatment, reflecting substantial healthcare resource utilization and significant impact on patient quality of life.

Documentation Requirements

✓Documented history of prior deep vein thrombosis
✓Explicit diagnosis of postthrombotic syndrome
✓Laterality specified (right lower extremity)
✓Ulcer characteristics documented (size, depth, location, wound bed description, drainage)
✓Signs of inflammation explicitly documented (erythema, warmth, tenderness, edema, induration)
✓Both ulcer AND inflammation must be present simultaneously — not just one component
✓Current treatment plan addressing both wound care and inflammatory component
✓Assessment of infection risk and antibiotic use if applicable

Commonly Confused Codes

I87.032 — Left lower extremity; ensure laterality matches documentation I87.01x — Postthrombotic syndrome with ulcer only, without inflammation; if inflammation is not documented, use this category I83.2xx — Varicose veins with ulcer and inflammation; the underlying etiology differs (prior deep vein thrombosis vs. primary varicose veins)I87.33x — Chronic venous hypertension with ulcer and inflammation; different etiology, no prior deep vein thrombosis history required L97.xxx — Non-pressure chronic ulcer of lower limb; should not be used when the ulcer is attributable to postthrombotic syndrome

Code Hierarchy

└I87Other disorders of veins └I87.0Postthrombotic syndrome └I87.03Postthrombotic syndrome with ulcer and inflammation └I87.031Postthrombotic syndrome with ulcer and inflammation of right lower extremity

└I87.031Postthrombotic syndrome with ulcer and inflammation of right lower extremity