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2025 ICD-10-CM code I81

Portal vein thrombosis or portal vein obstruction.

Coding should reflect the underlying cause of portal vein obstruction if identified, along with any significant associated conditions.Additional codes may be required to capture associated findings and complications.

Modifiers may apply to procedures performed in the context of managing portal vein thrombosis.Review payer-specific guidelines for appropriate modifier application.

Medical necessity for the diagnosis and treatment of portal vein thrombosis is established by the presence of symptoms consistent with portal vein obstruction (e.g., abdominal pain, ascites, jaundice, gastrointestinal bleeding), and confirmed by appropriate imaging studies. Treatment decisions are guided by the severity of the thrombosis and the presence of complications.

Diagnosis and management of portal vein thrombosis requires a multidisciplinary approach involving hepatologists, gastroenterologists, radiologists, and surgeons.Treatment may include anticoagulation, thrombolytic therapy, or surgical intervention depending on the severity and underlying cause.

IMPORTANT:Consider I82 (Other venous embolism and thrombosis) if the thrombosis is not in the portal vein.Specific subtypes of portal vein thrombosis may require further coding specificity.

In simple words: This code is for a blood clot in the vein that carries blood from your stomach and intestines to your liver.It can also mean a blockage in this vein from something other than a blood clot.

This code represents portal vein thrombosis, which is a blood clot in the portal vein, a large vein that carries blood from the digestive organs to the liver.It can also refer to obstruction of the portal vein due to other causes besides thrombosis.Excludes conditions such as hepatic vein thrombosis (I82.0), phlebitis of the portal vein (K75.1).

Example 1: A 55-year-old male with a history of cirrhosis presents with abdominal pain, ascites, and jaundice. Imaging reveals a complete occlusion of the portal vein.Code I81 is used to represent the portal vein thrombosis., A 40-year-old female with a history of inflammatory bowel disease develops portal hypertension, and imaging demonstrates a significant stenosis in the portal vein secondary to inflammation. Code I81 can be used for the portal vein obstruction., A 70-year-old patient post liver transplantation experiences a recurrence of portal vein thrombosis.Code I81 is appropriate for the diagnosis, and the documentation should specify the post-transplant status and any related complications.

Complete medical history including risk factors for portal vein thrombosis (e.g., cirrhosis, portal hypertension, abdominal trauma). Detailed physical examination findings.Imaging studies (ultrasound, CT scan, MRI) demonstrating the presence and extent of portal vein thrombosis or obstruction.Results of relevant laboratory tests (e.g., liver function tests, coagulation studies).

** The specificity of this code is important to ensure accurate reimbursement.Detailed clinical documentation is crucial to justify the diagnosis and any associated procedures.

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