Coding corner: Accurate coding of venous thrombosis and embolism

“Coding corner” is a series of coding tips that run in The Record each month.

With approximately 30 ICD-9 codes to choose from when diagnosing venous thrombosis and embolism, or VTE, there are many details that should be documented to support the proper choice of code.

These specifics can play a key role in selecting a code that will indicate medical necessity for the reimbursement of necessary treatment and services.

Codes for VTE can be found in Chapter 7, Diseases of the Circulatory System, indexed under category 453. The majority of the codes for VTE range from 453.0 through 453.9, with several codes in this range requiring a fifth digit to provide proper detail. There are also codes outside this range for VTE occurring during the peripartum period or in conjunction with other conditions.

The first specific that should be documented is the anatomic location of the VTE. It’s best practice to document the specific veins that are affected. In addition, documenting these other key factors will drive code selection:

• Deep or superficial vein
• Upper or lower extremity
• Distal or proximal portion of the extremity

Acuity of the condition should also be documented. Specific code selection will depend on whether the VTE is documented as:

• Acute
• Sub-acute
• Chronic or
• Past history

Typically, a chronic VTE is an old, previously diagnosed yet still present clot requiring continuation of anticoagulation therapy. While an acute clot is one that is newly diagnosed and requires treatment.

Code selection for sub-acute VTE should be classified to ICD-9 codes listed as acute. There are no set guidelines for when VTE is considered chronic, so the code selection for VTE will rely solely on the provider’s documentation. Coders should not assume that the clot is acute or chronic without documentation to support the code choice.

The phrase “history of” can have different meanings depending on its use. For example, “history of” as an old, active condition that is still being treated or “history of” as a past condition now treated prophylactically to prevent recurrence.

If an old VTE is present and requires further treatment, the codes for chronic VTE should be selected. If the patient has a past history of a thrombosis or embolism that is no longer present, and they’re being treated prophylactically, then the ICD-9 code V12.51, personal history of VTE, should be selected.

A patient’s medical record with documentation of “history of” VTE that does not provide specifics may require the coder to query the provider and request that they make appropriate documentation changes before the correct diagnosis can be applied.

The pending ICD-10 transition is scheduled for Oct. 1, 2015, and the importance of specific documentation will be more important than ever. ICD-9 provides approximately 30 codes for VTE, while ICD-10 increases that selection to more than 130 codes.

The additional ICD-10 codes will require coders to specify laterality as well as provide additional code choices to document veins affected by VTE.

For more information about this process, contact your provider consultant.

None of the information included in this article is intended to be legal advice and, as such, it remains the provider’s responsibility to ensure that all coding and documentation are done in accordance with applicable state and federal laws and regulations.