Wiki DVT vs History of DVT

[VanMetre6173]

Patient had a deep vein thrombosis in 2012 and a pulmonary embolism in April 2015. Patient is on Coumadin and came in for a refill and blood work Would I code these as history of or would I use the regular diagnosis codes since they are taking medication.

 

[rhondatalley]

This will depend on your documentation and you can look at related radiology to help paint the picture. Many times, patients are placed on anti-coagulants after a DVT or PE to prevent another from occurring. Look to make sure the PE or DVT is not documented as chronic. If not and your radiology looks OK, go with history of.

 

[CodingKing]

If the patient is just coming in for the standard refill and Coumadin checks I'd just bill the following

Z79.01 - Long term (current) use of anticoagulants
Z51.81 - Encounter for therapeutic drug level monitoring