According to the A.D.A.M. Medical Encyclopedia, a deep vein thrombosis (DVT) is the formation of a blood clot in a vein that is deep inside a part of the body, usually the legs. Deep venous thrombosis (DVT) mainly affects the large veins in the lower leg and thigh. The clot can block blood flow and cause swelling and pain. When a clot breaks off and moves through the bloodstream, this is called an embolism. An embolism can get stuck in the brain, lungs, heart, or other area, leading to severe damage.
Acute vs Chronic DVT
A DVT is considered acute when the occlusion is obstructing blood flow and causes pain and swelling. DVTs are labelled as chronic when the DVT exists for longer than 10 to 14 days. If documentation does not indicate whether the DVT is acute or chronic, code the DVT as acute.
Postoperative DVT
If a DVT is documented as postoperative or iatrogenic, assign code 997.2 Peripheral Vascular Complication, followed by a code for the DVT.
Symptoms
Swelling
Pain
Discoloration (redness) and warmth around the affected area.
The symptoms listed above are also associated with thrombophlebitis (inflammation of the vein with a blood clot). The physician may use the terms “DVT” and “thrombophlebitis” interchangeably. According to the AHA Coding Clinic for ICD-9-CM, if both thrombophlebitis and DVT are documented, only a code for the thrombophlebitis is assigned (category 451). (AHA Coding Clinic for ICD-9-CM, 1992, first quarter, pages 15-16).
Treatment
Anticoagulants, such as Coumadin and Pradaxa, are the main medications used to treat DVTs. These medications are also known as “blood thinners” because they decrease the blood’s ability to clot. Patients are usually on anticoagulant therapy for three to six months-these medications prevent other clots from forming, they do NOT resolve the existing clot. Assign code V58.61 as a secondary diagnosis if the patient is on an anticoagulant. If the DVT is resolved, you will report code V12.51 Personal History of Venous Thrombosis and Embolism.
PT/INR (Prothrombin time test/International Normalized Ratio) is blood test used to monitor to the effectiveness of anticoagulants in the blood. In order to code PT/INRs correctly, you should report V58.83 Drug Monitoring, followed by V58.61 Long-Term Anticoagulant Use. These codes should be reported together only when SN is performing this test.
In the Know 