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I82.409
ICD-10-CM
Acute Deep Venous Thrombosis

Learn about Acute Deep Venous Thrombosis (Acute DVT) diagnosis, including clinical documentation and medical coding for Acute Deep Vein Thrombosis. Find information on healthcare best practices related to Acute DVT and relevant medical terms for accurate and efficient documentation. This resource provides essential information for healthcare professionals dealing with Acute Deep Venous Thrombosis.

Also known as

Acute DVT
Acute Deep Vein Thrombosis

Diagnosis Snapshot

Key Facts
  • Definition : Blood clot forms in a deep vein, usually in the leg, causing pain and swelling.
  • Clinical Signs : Leg pain, swelling, warmth, redness, tenderness along the vein.
  • Common Settings : Hospitalized patients, post-surgery, prolonged immobility, trauma.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC I82.409 Coding
I80.2

Acute venous embolism and thrombosis

Covers acute deep vein thrombosis of lower extremities.

I80.1

Phlebitis and thrombophlebitis

Includes thrombophlebitis of superficial or deep vessels.

I82

Other venous embolism and thrombosis

Encompasses other specified venous embolism and thrombosis.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the DVT proximal (in the popliteal, femoral, or iliac veins)?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Blood clot in a deep vein, typically in the leg.
Blood clot in a lung artery, often originating from a DVT.
Inflammation of a superficial vein, usually in the leg.

Documentation Best Practices

Documentation Checklist
  • Document location, onset, laterality of DVT
  • Record signs/symptoms: pain, swelling, redness
  • Note D-dimer result and Wells score assessment
  • Specify diagnostic imaging: ultrasound, venography
  • Detail treatment plan: anticoagulants, thrombolysis

Coding and Audit Risks

Common Risks
  • Laterality Coding

    Missing or incorrect documentation of laterality (right, left, bilateral) can lead to coding errors and claim denials.

  • Proximal vs. Distal DVT

    Distinguishing between proximal and distal DVT is crucial for accurate coding and impacts treatment and reimbursement.

  • Complicating Factors

    Failing to document complicating factors like phlegmasia cerulea dolens or pulmonary embolism can lead to undercoding and lost revenue.

Mitigation Tips

Best Practices
  • Accurate DVT diagnosis coding: Use I80.2 for acute DVT.
  • CDI: Document DVT location, laterality, and symptoms.
  • DVT prophylaxis: Assess risk, prescribe anticoagulants per guidelines.
  • Monitor INR for warfarin, anti-Xa levels for other anticoagulants.
  • Compression therapy aids symptom relief, not DVT prevention.

Clinical Decision Support

Checklist
  • 1. Verify unilateral leg swelling, pain, or tenderness (ICD-10 I80.2)
  • 2. Assess D-dimer levels (CPT 82306) and interpret in clinical context.
  • 3. Order venous duplex ultrasound (CPT 93970) for suspected DVT location.
  • 4. Document Wells score for pretest probability and rationale for testing.

Reimbursement and Quality Metrics

Impact Summary
  • Medical billing: Accurate ICD-10 coding (I80.2) for Acute DVT ensures appropriate reimbursement.
  • Coding accuracy: Precise documentation of DVT laterality impacts payment and quality metrics.
  • Hospital reporting: Accurate DVT coding affects hospital-acquired condition (HAC) reporting and value-based purchasing.
  • Quality metrics: Timely diagnosis and treatment of Acute DVT improve patient outcomes and reduce VTE readmissions.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes. Our AI-powered assistant ensures compliance and reduces coding errors.

Frequently Asked Questions

Common Questions and Answers

Q: What are the most effective diagnostic imaging modalities for confirming suspected acute deep venous thrombosis (DVT) in the lower extremities, and how do their sensitivities and specificities compare?

A: When confirming suspected acute deep venous thrombosis (DVT) in the lower extremities, compression ultrasonography (CUS) is often the first-line imaging modality due to its accessibility and relatively low cost. CUS demonstrates high sensitivity (over 95%) and specificity (over 95%) for proximal DVT, though its accuracy decreases for distal DVT. If CUS is inconclusive or if there's a high clinical suspicion despite negative CUS, alternative imaging modalities such as venography (considered the gold standard but invasive), computed tomography venography (CTV), or magnetic resonance venography (MRV) may be considered. CTV and MRV are particularly useful for assessing iliac vein or inferior vena cava involvement. Explore how incorporating pre-test probability scoring, such as the Wells score or Geneva score, can further enhance the diagnostic accuracy of these imaging modalities in patients with suspected acute DVT. The choice of modality depends on patient-specific factors and local resources.

Q: Beyond anticoagulation, what other interventions should be considered in the management of acute deep vein thrombosis (DVT) to minimize post-thrombotic syndrome (PTS) risk and improve patient outcomes?

A: While anticoagulation is the cornerstone of acute deep vein thrombosis (DVT) treatment, several adjunctive interventions can be considered to mitigate the risk of post-thrombotic syndrome (PTS) and optimize patient outcomes. Early ambulation and graduated compression stockings (GCS) are recommended for most patients. Consider implementing strategies to enhance patient adherence to GCS therapy, as it plays a crucial role in reducing PTS incidence. In specific cases, catheter-directed thrombolysis (CDT) or pharmacomechanical thrombolysis may be considered for patients with extensive iliofemoral DVT or those at high risk of limb-threatening complications. Furthermore, inferior vena cava filters (IVCF) may be indicated in patients with contraindications to anticoagulation or recurrent DVT despite adequate therapy. Learn more about the role of individualized risk stratification in guiding the selection of appropriate adjunctive therapies for acute DVT.

Quick Tips

Practical Coding Tips
  • Code I80.2 for acute DVT
  • Query laterality for DVT code
  • Document PE signs/symptoms

Documentation Templates

Patient presents with signs and symptoms suggestive of acute deep venous thrombosis (acute DVT, acute deep vein thrombosis).  Presenting complaint includes [specific chief complaint, e.g., right lower extremity pain and swelling].  Onset of symptoms occurred [duration and timeframe].  Associated symptoms include [list associated symptoms, e.g., edema, erythema, warmth, tenderness along the affected vein].  Patient denies [list pertinent negatives, e.g., chest pain, shortness of breath, hemoptysis].  Physical examination reveals [objective findings, e.g., positive Homan's sign, palpable cord, edema measuring x cm].  Differential diagnosis includes muscle strain, cellulitis, Baker's cyst, and superficial thrombophlebitis.  Preliminary diagnosis of acute DVT is suspected.  Ordered D-dimer and venous duplex ultrasound of the [affected extremity] to confirm the diagnosis.  Wells score calculated as [score] indicating [low, moderate, or high probability].  Risk factors for DVT assessed, including [list applicable risk factors, e.g., recent surgery, prolonged immobility, oral contraceptive use, family history, active malignancy].  Pending ultrasound results, treatment plan may include anticoagulation therapy with [medication options and route of administration, e.g., low molecular weight heparin, unfractionated heparin, direct oral anticoagulants (DOACs)] for deep vein thrombosis treatment and prophylaxis of pulmonary embolism.  Patient education provided regarding DVT signs, symptoms, complications, and the importance of medication adherence.  Follow-up appointment scheduled for [date/time] to review results and adjust treatment plan as necessary.  ICD-10 code I80.2 (for unspecified deep vein thrombosis) considered pending diagnostic confirmation.  Further coding will be refined based on laterality and location once confirmed.