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Wiki Please help with DVT coding

tag60

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I have two questions about DVT coding.

First question:
On exam: Left arm with soft, tender mass, without warmth or redness, in the medial left upper arm. Full range of motion, full strength. Normal sensation, perfusion. Brisk cap refill.

Provider gives diagnosis of DVT and orders stat ultrasound to confirm. However, result comes back negative for DVT. Here I would code the symptoms, and am looking at R22.32, localized swelling, mass, and lump, left upper limb. Agree?

Second question:
Then he gives more results: Lower extremity Doppler - for DVT, + nonocclusive thrombus left femoral vein.

Isn't that statement contradictory? Isn't a thrombus of the left femoral vein a DVT?

Thanks in advance!
 
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