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I82.4Y1
ICD-10-CM
DVT of the Right Leg

Understanding DVT of the Right Leg: This guide provides essential information on Deep Vein Thrombosis Right Leg diagnosis, including clinical documentation, medical coding, and healthcare best practices for Right Leg DVT. Learn about symptoms, treatment, and prevention of DVT in the right leg.

Also known as

Deep Vein Thrombosis Right Leg
Right Leg DVT

Diagnosis Snapshot

Key Facts
  • Definition : Blood clot in a deep vein of the right leg.
  • Clinical Signs : Swelling, pain, redness, warmth in the right leg. May be asymptomatic.
  • Common Settings : Prolonged immobility (travel, bed rest), surgery, trauma, inherited clotting disorders.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC I82.4Y1 Coding
I82.40-I82.49

DVT of lower extremities

Deep vein thrombosis of the right leg

I80.0-I80.9

Phlebitis and thrombophlebitis

Inflammation of veins, sometimes with blood clots.

I82.0-I82.9

Other venous embolism and thrombosis

Covers other venous thrombosis and embolism not elsewhere classified.

Code-Specific Guidance

Decision Tree for

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

Is the DVT in the right leg proximal?

  • Yes

    Is there phlebitis?

  • No

    Is the DVT in the right leg calf?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right leg DVT
Left leg DVT
Pulmonary embolism

Documentation Best Practices

Documentation Checklist
  • DVT right leg: Location, onset, laterality documented
  • Right leg DVT: Signs/symptoms, e.g., swelling, pain
  • Deep vein thrombosis: Wells score or clinical prediction rule
  • DVT diagnosis: Supporting imaging study findings (ultrasound)
  • DVT right leg: Differential diagnosis considered and ruled out

Coding and Audit Risks

Common Risks
  • Laterality Specificity

    Coding and documentation must clearly specify "right leg" to avoid ambiguity and ensure accurate reimbursement. Missing laterality can lead to claim denials.

  • Clinical Validation

    Diagnosis requires appropriate clinical indicators documented in the medical record. Insufficient documentation may lead to audit discrepancies and coding errors.

  • Unilateral vs. Bilateral

    Accurate documentation differentiating unilateral (one leg) from bilateral (both legs) DVT is critical for proper coding and impacts severity and treatment.

Mitigation Tips

Best Practices
  • Accurate DVT laterality documentation: right leg specificity improves coding.
  • DVT diagnosis: Include symptom onset, location, and PE risk factors for CDI.
  • Thrombosis documentation: Specify if acute, chronic, or recurrent for proper coding.
  • DVT imaging results: Document Doppler ultrasound findings to support diagnosis code.
  • For recurrent DVT, document prior events and treatments for accurate risk assessment.

Clinical Decision Support

Checklist
  • Verify right leg pain/swelling: ICD-10 I80.21, SNOMED 34087006
  • Assess Homan's sign, calf tenderness: DVT diagnosis, patient safety
  • Review D-dimer, ultrasound findings: rule out other causes, coding accuracy
  • Evaluate risk factors: prior DVT, immobility, malignancy, I80.21

Reimbursement and Quality Metrics

Impact Summary
  • DVT Right Leg reimbursement impacts depend on accurate ICD-10 coding (I82.401) for optimal payment.
  • Coding quality affects hospital reporting on VTE incidence, impacting quality metrics and potential penalties.
  • Precise documentation of DVT laterality (right leg) is crucial for accurate coding and proper reimbursement.
  • Timely and specific DVT diagnosis coding impacts hospital quality scores related to venous thromboembolism.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . 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 deep vein thrombosis (DVT) in the right leg, and what are the key considerations when choosing between them?

A: When confirming suspected DVT in the right leg, the most effective diagnostic imaging modalities are compression ultrasonography (CUS) and venography. CUS is typically the first-line imaging test due to its non-invasive nature, high sensitivity, and cost-effectiveness. It assesses the compressibility of the vein; non-compressibility suggests the presence of a thrombus. Venography, involving the injection of contrast dye into the veins, is more invasive but offers higher specificity. It is usually reserved for cases where CUS is inconclusive or when interventional procedures are planned. Key considerations when choosing between CUS and venography include the patient's clinical presentation, accessibility of the modalities, and the potential risks associated with contrast dye. Explore how advancements in imaging technology are further improving DVT diagnosis accuracy.

Q: How do I differentiate between DVT of the right leg and other conditions that mimic its symptoms, such as cellulitis, Baker's cyst, or muscle strain, and what clinical findings should raise my suspicion for DVT?

A: Differentiating right leg DVT from mimicking conditions like cellulitis, Baker's cyst, or muscle strain requires a thorough clinical assessment. While all these conditions can present with leg pain and swelling, some key findings increase suspicion for DVT. These include unilateral leg swelling (predominantly in the calf), pitting edema, pain along the deep venous system, warmth, and bluish discoloration of the affected leg. Homans' sign (pain in the calf upon dorsiflexion of the foot) has low sensitivity and specificity, so it's not a reliable indicator. Consider implementing a scoring system like the Wells score or Geneva score to assess the clinical probability of DVT and guide further investigation with imaging studies like compression ultrasonography if deemed necessary. Learn more about the specific clinical features that distinguish DVT from other lower limb conditions.

Quick Tips

Practical Coding Tips
  • Code I80.21 for right leg DVT
  • Document DVT location precisely
  • Query physician if DVT extent unclear
  • Consider risk factors in documentation
  • Review Wells criteria documentation

Documentation Templates

Patient presents with complaints concerning right leg discomfort, suggestive of deep vein thrombosis (DVT).  Symptoms include right lower extremity pain, swelling, and tenderness along the deep venous system.  The patient reports onset of symptoms approximately [duration] ago.  Physical examination reveals [positive findings e.g., edema, erythema, warmth, palpable cord, Homan's sign (if present but note its low specificity), and limited range of motion].  Differential diagnoses include muscle strain, cellulitis, Baker's cyst, and superficial thrombophlebitis.  To evaluate for right leg DVT, a venous duplex ultrasound study of the right lower extremity has been ordered.  Assessment includes right lower extremity DVT versus other potential etiologies of leg pain and swelling.  Plan includes pending ultrasound results, potential initiation of anticoagulant therapy such as direct oral anticoagulants (DOACs) or low molecular weight heparin (LMWH) for DVT treatment, patient education on DVT risk factors and preventative measures, and close follow-up to monitor treatment response and potential complications like pulmonary embolism (PE).  ICD-10 code I80.21 (right leg DVT) is considered pending diagnostic confirmation.  Further evaluation and management will be determined based on the ultrasound findings.
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