I82.4Y1

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

Acute embolism and thrombosis of deep veins of the right lower extremity (unspecified) is a critical vascular condition involving the formation or lodging of a blood clot within the deep venous system of the right leg. Unlike superficial venous thrombosis, deep vein thrombosis (DVT) carries a significant risk of morbidity and mortality due to the potential for the clot to detach and migrate to the pulmonary arteries, resulting in a life-threatening pulmonary embolism (PE). The 'acute' designation typically refers to a clot formed within the last 14 days, which is generally more inflammatory and less adherent to the vessel wall than a chronic thrombus. This specific code is used when clinical documentation confirms the presence of an acute DVT in the right lower extremity but does not specify the exact deep vessel involved (such as the femoral or popliteal veins), or when it involves a deep vein categorized under the 'other specified' or 'unspecified' classification in the right leg.

Clinical Symptoms

  • Unilateral swelling (edema) of the right leg or calf
  • Localized pain or tenderness in the right lower extremity
  • Warmth or heat over the affected area of the right leg
  • Erythema or bluish skin discoloration (cyanosis) of the right leg
  • Palpable venous 'cord' or thickening along the deep venous course
  • Leg fatigue or heaviness, particularly when standing or walking
  • Distension of superficial collateral veins in the right leg
  • Positive Homans' sign (pain in the calf upon dorsiflexion of the foot)
  • Pitting edema restricted to the right extremity

Common Causes

  • Venous stasis resulting from prolonged immobility or bed rest
  • Vascular endothelial injury due to trauma or orthopedic surgery
  • Hypercoagulable states (e.g., malignancy, Factor V Leiden, Protein C or S deficiency)
  • Recent major surgery, particularly hip or knee replacement
  • Pregnancy and the immediate postpartum period
  • Exogenous estrogen use (oral contraceptives or hormone replacement therapy)
  • Advanced age and obesity
  • Active cigarette smoking
  • History of prior venous thromboembolism (VTE)

Documentation & Coding Tips

Document the specific vein involved when known to avoid unspecified codes.

Example: Patient presents with a 2-day history of right calf swelling and pain. Venous duplex ultrasound confirms an acute deep vein thrombosis in the right peroneal vein. Plan: Start Apixaban 10mg BID for 7 days then 5mg BID. Risk: High risk of recurrence due to active malignancy (HCC condition). Laterality: Right lower extremity. Site: Peroneal vein. Episode: Initial.

Billing Focus: Specifying the exact vein (e.g., peroneal, tibial) is required for higher specificity codes, though I82.4Y1 serves as the catch-all for unspecified deep veins of the right leg.

Indicate if the DVT is provoked or unprovoked to support medical necessity for long-term anticoagulation.

Example: Evaluation of acute DVT of the right lower extremity. Condition is unprovoked with no recent surgery or immobilization. Genetic testing for Factor V Leiden ordered. Diagnosis: I82.4Y1. Billing: Right laterality confirmed. Documentation supports the need for extended anticoagulant therapy (Z79.01).

Billing Focus: Laterality and the 'acute' nature must be explicitly stated to support I82.4Y1 over chronic codes.

Always document the presence or absence of associated Pulmonary Embolism.

Example: Patient diagnosed with acute deep vein thrombosis of the right lower extremity unspecified vein. CTA chest performed to rule out pulmonary embolism; results were negative. Patient stable for outpatient management. Billing: Primary code I82.4Y1. Secondary code Z86.718 (Personal history of venous thrombosis) not applicable as this is acute.

Billing Focus: The absence of PE must be documented to justify using only the I82.4Y1 code without supplemental I26 series codes.

Clarify the 'acute' status versus 'chronic' or 'history of' to ensure correct code selection.

Example: Acute onset of right lower extremity edema. Ultrasound confirms new acute thrombosis in the deep venous system of the right leg. This is not a recurrence of her previous 2018 DVT. Billing: I82.4Y1 (Acute). Risk: Acute status triggers the HCC 108 weight for the current performance year.

Billing Focus: Clinical descriptors such as 'new onset', 'fresh clot', or 'non-organized thrombus' support the 'acute' ICD-10 designation.

Document the clinical decision-making and complexity to support E/M levels.

Example: Patient with acute right leg DVT. Reviewed ultrasound and laboratory data (PT/INR, CBC). Discussed risks of bleeding versus thrombosis with Eliquis. Moderate complexity MDM due to the need for systemic anticoagulation and monitoring for PE symptoms. Total time spent 35 minutes.

Billing Focus: Time and MDM complexity support 99214. Explicit mention of anticoagulation management justifies moderate complexity.

Relevant CPT Codes

Related Diagnoses

Hierarchy