2025 ICD-10-CM code I82.401
(Active) Effective Date: N/A Diseases of the circulatory system - Diseases of veins, lymphatic vessels and lymph nodes, not elsewhere classified 9 Feed
Acute embolism and thrombosis of unspecified deep veins of right lower extremity.
Medical necessity for the diagnosis and treatment of acute DVT is established by the presence of signs, symptoms, and/or diagnostic findings indicative of the condition. The medical record should demonstrate the severity of the condition and the potential risk of complications such as pulmonary embolism, which justifies the need for intervention.
Diagnosis and management of deep vein thrombosis (DVT) in the right lower extremity falls under the purview of various medical specialists, including vascular surgeons, interventional radiologists, hematologists, internists, and hospitalists.Clinical responsibilities encompass obtaining a thorough medical history, performing a physical examination focused on the affected extremity, ordering appropriate diagnostic tests (e.g., venous duplex ultrasound, D-dimer), assessing the patient's risk factors for DVT and pulmonary embolism (PE), initiating anticoagulant therapy, and monitoring the patient's response to treatment. In some cases, they might recommend additional interventions like thrombolysis or inferior vena cava filter placement.
In simple words: A blood clot has formed in a deep vein in your right lower leg. This clot is blocking blood flow.
Acute embolism and thrombosis of unspecified deep veins of right lower extremity.
Example 1: A 65-year-old male presents to the emergency room with right lower leg swelling and pain. A venous duplex ultrasound confirms the presence of acute DVT in the right lower extremity. The patient is admitted to the hospital and started on anticoagulant therapy., A 40-year-old female undergoes a total knee replacement surgery. Postoperatively, she develops swelling and tenderness in her right calf. Doppler ultrasound reveals acute DVT. She is prescribed anticoagulants and discharged with instructions for follow-up care., A 25-year-old male with a history of Factor V Leiden presents with pain and edema in his right lower leg following a long international flight.Anticoagulant therapy is initiated based on the diagnosis of acute DVT confirmed by diagnostic imaging.
Documentation for I82.401 should include: location of the DVT (right lower extremity, specifying the affected vein if known), acuity of the condition (acute), signs and symptoms, diagnostic test results confirming the diagnosis (e.g., ultrasound findings), risk factors for DVT, and treatment plan including anticoagulant medication, if prescribed. Laterality (right lower extremity) is crucial for accurate coding.
- Payment Status: Active
- Specialties:Vascular Surgery, Interventional Radiology, Hematology, Internal Medicine, Hospital Medicine, Family Medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office, Outpatient Hospital, Home, Skilled Nursing Facility,Ambulance - Land, Other Place of Service