ICD-10 Coding for Right Leg Deep Vein Thrombosis(I82.4X1, I82.411)
Complete ICD-10-CM coding and documentation guide for Right Leg Deep Vein Thrombosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Leg Deep Vein Thrombosis
I82.4-I82.5Primary Range
Embolism and thrombosis of veins of lower extremities
This range includes codes for acute and chronic DVT of the lower extremities, specifying laterality and vein involvement.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I82.4X1 | Acute embolism and thrombosis of unspecified deep veins of right lower extremity | Use when documentation lacks specific vein details for acute DVT in the right leg. |
|
| I82.411 | Acute embolism and thrombosis of right femoral vein | Use when acute DVT is confirmed in the right femoral vein. |
|
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 right leg DVT
Essential facts and insights about Right Leg Deep Vein Thrombosis
Primary ICD-10-CM Codes for right leg dvt
Decision Criteria
clinical Criteria
- Confirmed acute DVT in right leg without specific vein documentation
Applicable To
- Acute DVT of right leg without specific vein documentation
Excludes
- Chronic DVT (I82.5X1)
Clinical Validation Requirements
- Ultrasound confirmation of noncompressible vein
- D-Dimer >500 ng/mL with Wells score ≥2
Code-Specific Risks
- Risk of under-documentation leading to incorrect coding
Coding Notes
- Ensure vein specificity is documented to avoid defaulting to unspecified codes.
I82.411 - Acute embolism and thrombosis of right femoral vein
Use when acute DVT is confirmed in the right femoral vein.
Applicable To
- Acute DVT of right femoral vein
Excludes
- Chronic DVT of right femoral vein (I82.511)
Clinical Validation Requirements
- Ultrasound confirmation of noncompressible femoral vein
Coding Notes
Ensure documentation specifies the femoral vein to use this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Long-term (current) use of anticoagulants
Z79.01Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right Leg Deep Vein Thrombosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I82.4X1.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Increases risk of coding audits., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure thorough documentation of ultrasound findings, Use templates to guide documentation
Impact
Reimbursement: May result in lower reimbursement due to lack of specificity., Compliance: Increases risk of audits due to non-specific coding., Data Quality: Reduces accuracy of clinical data for research and analysis.
Mitigation Strategy
Ensure documentation specifies the affected vein to use the most specific code.
Impact
Audits may focus on the specificity of vein documentation in DVT cases.
Mitigation Strategy
Ensure all clinical documentation includes specific vein involvement.
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 Right Leg Deep Vein Thrombosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Leg Deep Vein Thrombosis
Use these documentation templates to ensure complete and accurate documentation for Right Leg Deep Vein Thrombosis. These templates include all required elements for proper coding and billing.
Emergency Department Presentation
Specialty: Emergency MedicineRequired Elements
- Patient age and presenting symptoms
- Physical exam findings
- Ultrasound results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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