Wiki Coding DVT vs history of

[warrenfamily103@gmail.com]

I am trying to code DVT and the documentation states history of but it also says patient is on Eliquis for treatment. Based on guidelines I'm seeing, if they are still being treated then it can be coded as active. I appreciate any input.

 

[thomas7331]

I don't have a clinical background on DVTs, so I could be wrong on this, but my understanding is that the Eliquis could be either for treatment of a DVT or for prevention of new DVTs if the patient has had a history. I have seen charts of patients who continue on anticoagulant therapy even after their DVT is resolved, so I don't think this would be considered treatment of an active problem in the same way as would be, for example, chemotherapy for a tumor that has been removed. So my recommendation would be that if the documentation is not clear as to whether the DVT is a current condition or is resolved and history, the best approach would be to query the provider.

 

[mk2001]

I usually code the DVT & Z79.01. If they no longer have the DVT and still on Eliquis, I code Z86.718 & Z79.01.

 

[twizzle]

We all know that providers are notoriously bad at documenting whether a problem truly is 'history of' because their perception of this wording is that the patient has had the condition at some time and it is now resolved, or still has the condition; no distinction is made between the two. Your only real way of knowing is by initiating a provider query if that is in your remit.
It is true that anticoagulants are often given for prevention after a DVT has been treated for a patient considered 'at risk' for further DVT, but it is also obviously true that they are given to patients being treated for a current problem. Based on your documentation I would code the Z86.718 and Z79.01. You can only code from the documentation...no assumptions.