Understanding a patient's history of blood clots is crucial for accurate diagnosis and treatment. This resource explores key clinical documentation and medical coding terms related to a history of deep vein thrombosis, pulmonary embolism, venous thromboembolism, and thrombophilia. Learn about the importance of documenting prior clot locations, recurrence, family history, and relevant risk factors for improved healthcare outcomes. This information is vital for physicians, nurses, medical coders, and other healthcare professionals involved in patient care and accurate medical record keeping.
Also known as
Other venous embolism and thrombosis
History of venous blood clots, excluding specific locations.
Personal history of venous embolism
Personal history of venous thromboembolism (VTE).
Pulmonary embolism without acute cor pulmonale
Includes past pulmonary embolisms (blood clots in lungs).
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the blood clot location documented?
Yes
Specify clot location.
No
Code as personal history of venous thrombosis, unspecified (Z86.718)
When to use each related code
Description |
---|
History of blood clots (venous) |
History of pulmonary embolism (PE) |
History of deep vein thrombosis (DVT) |
Coding blood clots without specifying the affected vein or artery leads to inaccurate severity and treatment reflection.
Miscoding active blood clots as history or vice versa impacts patient safety and reimbursement due to differing acuity.
Failing to code the underlying cause of the blood clot, if known, hinders accurate quality reporting and risk adjustment.
Patient presents with a history of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). The initial DVT occurred in [Month, Year] affecting the [Location of DVT: e.g., left lower extremity]. Diagnosis was confirmed by [Diagnostic method: e.g., venous duplex ultrasound]. Subsequent [or concurrent] PE was diagnosed in [Month, Year] based on [Diagnostic method: e.g., CT angiography of the chest]. Risk factors for thrombosis include [List risk factors: e.g., prior surgery, prolonged immobilization, family history, oral contraceptives, factor V Leiden mutation, prothrombin gene mutation, antiphospholipid syndrome]. Patient was initially treated with [Initial treatment: e.g., heparin, enoxaparin] followed by [Long-term treatment: e.g., warfarin, rivaroxaban, apixaban, dabigatran, edoxaban] for [Duration of treatment: e.g., 3 months, 6 months, indefinitely]. Current INR is [INR Value, if applicable]. Patient reports [Current symptoms: e.g., no current symptoms, residual swelling, shortness of breath, chest pain]. Physical examination reveals [Physical exam findings: e.g., no edema, mild edema of the left lower extremity, normal lung sounds]. Assessment: History of VTE, [Specify type: e.g., provoked, unprovoked], currently [Status: e.g., stable, symptomatic, asymptomatic] on [Current treatment: e.g., anticoagulation therapy]. Plan: Continue current anticoagulation as prescribed. Monitor for signs and symptoms of recurrent VTE. Patient education provided regarding medication compliance, bleeding precautions, and follow-up appointments. Follow-up in [Timeframe: e.g., 3 months, 6 months] for reassessment of anticoagulation needs.