ED Coding and Reimbursement Alert

Question: Encounter notes indicate that a patient suffers from an acute embolism in their right lower extremity. I have no other information on the patient’s diagnosis. What is the most appropriate ICD-10-CM code for this condition?

New York Subscriber

Answer: It looks like you’ll have to opt for an unspecified code for this patient, since you have very little information to work with. For this diagnosis, however, even the unspecified codes require some digging.

Look at the encounter notes again, paying attention to where in the extremity the embolism occurred. Then, you can choose the proper unspecified ICD-10-CM code from the following options:

• Option 1: If the patient’s embolism occurred in the proximal lower extremity, report I82.4Y1 (Acute embolism and thrombosis of unspecified deep veins of right proximal lower extremity).
• Option 2: If the patient’s embolism occurred in the distal lower extremity, report I82.4Z1 (Acute embolism and thrombosis of unspecified deep veins of right distal lower extremity).
• Option 3: If there is no indication where in the patient’s lower extremity the embolism occurred, opt for I82.401 (Acute embolism and thrombosis of unspecified deep veins of right lower extremity).

As you can see from the descriptors, you need to know the definitions of proximal and distal to use these ICD-10-CM codes correctly. Proximal parts of the lower extremities are closest to the patient’s trunk. Proximal parts include the hips, the thighs, and the knees.

Distal parts of the lower extremities, on the other hand, are the ones furthest from the patient’s trunk. Distal parts include the ankles, the feet, and the toes.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC