Wiki Report doesn't indicate acute or chronic DVT

[she803]

...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]

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]

...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