General Surgery Coding Alert

Question: What documentation should our vascular surgeons provide for DVT diagnosis using ICD-10?

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Answer: Coding for deep vein thrombosis (DVT) in ICD-10 will require that your surgeon document details such as which specific deep vein is involved, and on which side. 

Diagnosis refresher: A thrombosis is a solid mass that forms locally in a vessel causing an obstruction. An embolism is most often a piece of a thrombus broken free and carried by the bloodstream causing obstruction of a vessel. Plaque or fatty deposits typically form the obstructions. 

Remember: Don’t report the DVT codes for thrombosis in superficial veins. The following ICD-10 codes apply to acute DVT cases:

• I82.44_ — Acute embolism and thrombosis of ____ tibial vein
  
• I82.49_ — Acute embolism and thrombosis of other specified deep vein of ____ lower extremity
  
• I82.4Z_ — Acute embolism and thrombosis of unspecified deep veins of ____distal lower extremity
  

Each of the preceding ICD-10 codes are incomplete without the final digit. Choose the sixth character based on the side(s) involved:

• 1 — right
  
• 2 — left
  
• 3 — bilateral
  
• 9 — unspecified.