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ICD-10 Coding for Deep Vein Thrombosis of the Right Lower Extremity(I82.401, I82.432)

Complete ICD-10-CM coding and documentation guide for Deep Vein Thrombosis of the Right Lower Extremity. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

DVT RLERight Leg DVTRight Lower Extremity DVT

Related ICD-10 Code Ranges

Complete code families applicable to Deep Vein Thrombosis of the Right Lower Extremity

I82.4-I82.5Primary Range

Embolism and thrombosis of veins

This range includes codes for acute and chronic DVT, specifying laterality and vein location.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
I82.401Acute embolism and thrombosis of unspecified deep veins of right lower extremityUse when DVT is confirmed in the right lower extremity but the specific vein is not documented.
  • Imaging confirmation of DVT
  • Clinical symptoms such as swelling and pain
I82.432Acute embolism and thrombosis of right popliteal veinUse when DVT is confirmed in the right popliteal vein.
  • Ultrasound showing non-compressible popliteal vein
  • Symptoms consistent with DVT

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for DVT right lower extremity

Essential facts and insights about Deep Vein Thrombosis of the Right Lower Extremity

The ICD-10 code for acute DVT of the right lower extremity is I82.401, used when the specific vein is not documented.

Primary ICD-10-CM Codes for deep vein thrombosis right lower extremity

Acute embolism and thrombosis of unspecified deep veins of right lower extremity
Billable Code

Decision Criteria

documentation Criteria

  • Document laterality and confirm with imaging.

Applicable To

  • Acute DVT of unspecified deep veins in the right leg

Excludes

  • Superficial thrombophlebitis (I80.8)

Clinical Validation Requirements

  • Imaging confirmation of DVT
  • Clinical symptoms such as swelling and pain

Code-Specific Risks

  • Risk of audit if specific vein is not documented

Coding Notes

  • Ensure documentation specifies 'acute' and 'right lower extremity'.

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Long term (current) use of anticoagulants

Z79.01
Use to indicate ongoing anticoagulation therapy.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Phlebitis and thrombophlebitis of other sites

I80.8
Use for superficial thrombophlebitis, not deep vein thrombosis.

Chronic embolism and thrombosis of right iliac vein

I82.521
Use for chronic conditions with documented history of DVT.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Deep Vein Thrombosis of the Right Lower Extremity to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I82.401.

Impact

Clinical: May lead to inappropriate treatment decisions., Regulatory: Increases risk of audit and compliance issues., Financial: Potential for reduced reimbursement.

Mitigation Strategy

Ensure imaging reports specify the vein., Include detailed clinical notes.

Impact

Reimbursement: May lead to reduced reimbursement if specificity is not documented., Compliance: Increases risk of audit due to lack of specificity., Data Quality: Decreases accuracy of clinical data.

Mitigation Strategy

Ensure documentation specifies the exact vein involved.

Impact

Increased audit risk when using unspecified DVT codes without justification.

Mitigation Strategy

Document specific vein involvement whenever possible.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for Deep Vein Thrombosis of the Right Lower Extremity, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Deep Vein Thrombosis of the Right Lower Extremity

Use these documentation templates to ensure complete and accurate documentation for Deep Vein Thrombosis of the Right Lower Extremity. These templates include all required elements for proper coding and billing.

Emergency Department Presentation

Specialty: Emergency Medicine

Required Elements

  • Patient history
  • Physical exam findings
  • Imaging results
  • Diagnosis
  • Treatment plan

Example Documentation

Patient presents with right leg swelling and pain. Ultrasound confirms non-compressible right popliteal vein. Diagnosis: Acute DVT right popliteal vein. Initiated anticoagulation therapy.

Examples: Poor vs. Good Documentation

Poor Documentation Example
Patient has DVT in right leg.
Good Documentation Example
Acute DVT in right popliteal vein confirmed by ultrasound, patient started on enoxaparin.
Explanation
The good example specifies the vein and confirms diagnosis with imaging.

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