• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below.
  • We're introducing new features and a new look to make the forums easier to use and more valuable to you. See what's new and let us know what you think!

Report doesn't indicate acute or chronic DVT

she803

Networker
Messages
92
Best answers
0
...So should I report Dx 453.40 or 453.86?

Clinical History: Evaluate for DVT.

Comment: Sonographic examination venous system right proximal upper extremity. No prior study for comparison. Nonocclusive intraluminal filling defect within the visualized right internal jugular vein compatible with thrombus. Color Doppler flow within the visualized right subclavian vein. Visualized right axillary as well as proximal and mid right brachial veins appear compressible and demonstrate flow. Cephalic and basilic veins not identified. Preliminary report: Date:?Feb 17, 2012 00:25:32 Subject: right IJ clot d/w Murphy

Impression: Nonocclusive venous thrombosis right internal jugular vein.
 

ollielooya

True Blue
Messages
897
Location
Everett, WA
Best answers
0
personally I think your first code choice would not be correct. It's in the wrong area. Here's an older link I have that contains some good information that may help you. In addition it references Coding Assistant. This is just good stuff to have for reference even if it is older. If someone has more recent info or can supply additional information, I'm sure you would appreciate that as well, at least this is a start:

http://www.fortherecordmag.com/archives/ftr_031609p27.shtml
 

dpeoples

True Blue
Messages
890
Location
Birmingham, Alabama
Best answers
0
...So should I report Dx 453.40 or 453.86?

Clinical History: Evaluate for DVT.

Comment: Sonographic examination venous system right proximal upper extremity. No prior study for comparison. Nonocclusive intraluminal filling defect within the visualized right internal jugular vein compatible with thrombus. Color Doppler flow within the visualized right subclavian vein. Visualized right axillary as well as proximal and mid right brachial veins appear compressible and demonstrate flow. Cephalic and basilic veins not identified. Preliminary report: Date:?Feb 17, 2012 00:25:32 Subject: right IJ clot d/w Murphy

Impression: Nonocclusive venous thrombosis right internal jugular vein.
Under the heading thrombosis, vein, internal jugular the word acute is in parenthesis. This means that is a non-essential modifier and does not have to be documented to affect the code assignment. However, the word "chronic" appears as a subheading which makes that an essential modifier which does affect code assignment. Therefore ICD9 453.86is for thrombosis of the internal jugular vein not specified as chronic. As a general rule, any condition should be assumed (yes I know) to be acute unless documented as chronic.

Do not use 453.40. that is for deep vessels of the lower extremity.

HTH :)
 
Top