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2025 ICD-10-CM code I82.4Y1

Acute embolism and thrombosis of unspecified deep veins of the right proximal lower extremity.

Follow official ICD-10-CM coding guidelines and conventions.Ensure accurate selection based on the specific clinical findings and documentation.

Modifiers may be applicable depending on the circumstances of service.Always check for relevant modifiers according to the payer's guidelines.

Medical necessity for coding I82.4Y1 is established by documentation supporting the presence of acute symptoms (pain, swelling, erythema) and a clinical diagnosis of deep vein thrombosis, potentially confirmed by imaging studies.The medical necessity may be further strengthened by the identification of underlying risk factors that increase the likelihood of DVT and potential complications such as pulmonary embolism.

The clinical responsibility for this diagnosis would typically involve a physician specializing in vascular surgery, hematology, or internal medicine.Diagnostic testing, such as ultrasound or venography, might be ordered.Treatment might include anticoagulation therapy (e.g., heparin, warfarin, or newer oral anticoagulants).

IMPORTANT:Related codes include I82.4Y2 (left side) and I82.4Y3 (bilateral).More specific codes exist if the affected vein is known (e.g., femoral, iliac, popliteal veins).

In simple words: This code describes a blood clot (thrombosis) or blockage (embolism) in a deep vein in the upper part of the right leg. The exact vein isn't specified.

This ICD-10-CM code signifies acute embolism and thrombosis affecting unspecified deep veins in the right proximal lower extremity.The location is specified as the right side, and the affected area is the proximal (upper) part of the lower extremity.The specific vein(s) involved are not identified.

Example 1: A 60-year-old male presents with right leg pain, swelling, and redness after a long flight.A venous duplex ultrasound reveals thrombosis in the right proximal lower extremity, unspecified vein., A 35-year-old female recovering from a recent surgery develops symptoms consistent with deep vein thrombosis in her right thigh, confirmed by ultrasound.Specific vein identification is not possible., A 72-year-old patient with a history of atrial fibrillation experiences sudden onset of right leg pain and swelling. An emergency room visit leads to diagnosis of deep vein thrombosis in the proximal right leg.

Detailed history including risk factors (e.g., recent surgery, prolonged immobility, pregnancy, trauma, hypercoagulability), physical exam noting location and extent of swelling, redness, and tenderness.Imaging studies (ultrasound or venography) to confirm diagnosis and specify location if possible.Laboratory tests may include D-dimer and other coagulation studies.Treatment plan, response to treatment, and follow-up care should also be documented.

** This code is used when the specific deep vein involved in the thrombosis or embolism cannot be precisely identified within the right proximal lower extremity. If specific vein is identified, then a more precise code should be used.Always use the most specific code possible.

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