I82.419

Acute embolism and thrombosis of unspecified deep vein of right lower extremity

I82.419 represents a specific diagnosis of an acute deep vein thrombosis (DVT) occurring in the right lower extremity where the specific vein involved (such as the femoral, popliteal, or tibial veins) has not been documented or identified. Acute DVT is characterized by the sudden formation of a blood clot within the deep venous system, which poses a significant clinical risk for pulmonary embolism (PE) if the thrombus dislodges. This condition is a medical emergency requiring prompt anticoagulation or mechanical intervention to prevent extension of the clot and secondary complications like post-thrombotic syndrome (PTS). The diagnosis is usually confirmed via compression ultrasonography with Doppler or, in less common scenarios, CT venography or MRI.

Clinical Symptoms

  • Unilateral swelling of the right leg (edema)
  • Localized pain or tenderness along the distribution of the deep venous system
  • Warmth of the skin over the affected area
  • Erythema or bluish discoloration of the right lower extremity
  • Pitting edema
  • Visible superficial collateral veins
  • Positive Homan's sign (discomfort behind the knee on forced dorsiflexion of the foot, though non-specific)
  • Tenderness in the calf or thigh upon palpation
  • Sense of fullness or heaviness in the right leg

Common Causes

  • Venous stasis (prolonged immobility, long-distance travel, or paralysis)
  • Endothelial injury (trauma to the leg, orthopedic surgery, or intravenous catheterization)
  • Hypercoagulable states (Factor V Leiden, Protein C or S deficiency, Antithrombin III deficiency)
  • Malignancy (active cancer or chemotherapy treatment)
  • Pregnancy and the postpartum period
  • Use of oral contraceptives or hormone replacement therapy
  • Advanced age (risk increases significantly over age 60)
  • Obesity
  • Previous history of venous thromboembolism (VTE)
  • Inflammatory bowel disease or other systemic inflammatory conditions

Documentation & Coding Tips

Document the specific vein involved to avoid the unspecified code.

Example: Patient presents with acute onset right calf swelling and pain. Duplex ultrasound of the right lower extremity reveals an acute, non-compressible thrombus in a deep venous structure of the right leg, not otherwise specified by the radiologist. Given the clinical presentation and positive D-dimer, the diagnosis is acute deep vein thrombosis of the right lower extremity. The patient has a comorbid BMI of 42.5 (E66.01, Z68.41), which complicates management and increases risk adjustment severity.

Billing Focus: Specifying laterality as right and identifying the vein as deep rather than superficial is critical for accurate code selection.

Clarify the stage of the thrombus as acute versus chronic.

Example: Evaluation of right leg heaviness and edema. History of sedentary lifestyle. Ultrasound confirms an acute embolism and thrombosis of an unspecified deep vein of the right lower extremity. There is no evidence of post-thrombotic syndrome or chronic changes at this time. Initiating therapeutic anticoagulation. Risk is elevated due to the patients underlying advanced stage prostate cancer (C61).

Billing Focus: The I82.4 series denotes acute conditions, whereas I82.5 denotes chronic conditions. Incorrect classification impacts clinical validity and billing.

Include relevant clinical scoring systems like Wells Criteria.

Example: Clinical suspicion for right leg DVT is high (Wells score of 3: active cancer, calf swelling >3cm compared to left, and pitting edema). Venous duplex confirms acute thrombosis in a deep vein of the right lower extremity. No specified vein was identified in the imaging report. Patient is started on Enoxaparin bridge to Warfarin. Documenting the clinical score justifies the medical necessity of the diagnostic ultrasound.

Billing Focus: Documentation of clinical indicators like the Wells score supports the medical necessity of imaging procedures (CPT 93971).

Document the presence or absence of pulmonary embolism symptoms.

Example: Patient diagnosed with acute thrombosis of an unspecified deep vein of the right lower extremity. Negative for shortness of breath, chest pain, or tachycardia. Chest CT angiography was negative for pulmonary embolism. This maintains the diagnosis as isolated lower extremity DVT. Plan includes monitoring for signs of embolization and anticoagulation for 3 to 6 months.

Billing Focus: Differentiating between isolated DVT and DVT with pulmonary embolism (I26 series) is vital for accurate DRG assignment in inpatient settings.

Capture long-term anticoagulation therapy status.

Example: Following the diagnosis of acute deep vein thrombosis of the unspecified deep vein of the right lower extremity, the patient was started on Apixaban. Patient will require long-term anticoagulation monitoring. Code Z79.01 should be appended in subsequent encounters to reflect ongoing medication management for this condition.

Billing Focus: Coding for long-term use of anticoagulants (Z79.01) provides a complete picture of the patients therapeutic regimen.

Relevant CPT Codes

Related Diagnoses

Hierarchy