How to Code a Resolving DVT

Deep vein thrombosis (DVT) occurs when a blood clot develops in a deep vein of the legs or thighs. Most DVT will resolve with treatment, although if the blood clot breaks free it can travel to the lungs where it is termed a pulmonary embolism. The International Classification of Diseases (ICD) codes DVT and other medical conditions. The ICD is published and copyrighted by the World Health Organization, with the 9th revision, Clinical Modification (ICD-9-CM) published by the United States Government.

Instructions

• 1

  Review the patient's chart to determine if the DVT is acute. If Doppler ultrasound just confirmed the presence of DVT, and the patient received a new anticoagulant prescription, code it as 453.4 "acute venous embolism and thrombosis of deep vessels of lower extremity". Use the fifth digit to identify the location of the DVT: 0 for "Deep vein thrombosis Not Otherwise Specified" (NOS), 1 for "Femoral, iliac, popliteal, thigh, upper leg NOS", or 2 for "Calf, lower leg NOS, peroneal, tibial".

• 2

  Identify if the DVT is a previous condition that is still under active treatment. In other words, there still exists a present but resolving DVT. In this case, it is termed a chronic DVT. For chronic/resolving DVT use code 453.5 "Chronic venous embolism and thrombosis of deep vessels of lower extremity." Use the fifth digit to identify the location of the DVT: 0 for "Deep vessels of lower extremity," 1 for "Deep vessels of proximal lower extremity," 2 for "Deep vessels of distal lower extremity." Add code V58.61 "Long-term (current) use of anticoagulants" when coding a resolving DVT.

• 3

  Confirm that the DVT is no longer present; that it has completely resolved. For this patient there may be anticoagulant follow-up prescriptions for a history of recurrent DVT or risk of recurrent DVT. In this case, it is no longer an active DVT but rather a history of DVT. Use ICD-9-CM codes V58.61, "Encounter for long-term (current) use of anticoagulants" and code V12.51, "Personal history of venous thrombosis and embolism."