Coding corner: Best practices for documenting peripheral vascular disease and deep vein thrombosis

Delivering high-quality treatment and care to members is a high priority for Blue Cross Blue Shield of Michigan. And proper clinical documentation is crucial, as it ensures complete, consistent and accurate information about a patient encounter. For all medical conditions, including vascular disease, it’s necessary to follow the ICD-10-CM guidelines before assigning the appropriate code.

About vascular disease
Vascular disease is an abnormal condition of the blood cells and includes conditions affecting the circulatory system. The vascular system is the body’s network of blood vessels. It includes the arteries, veins and capillaries that carry blood to and from the heart.

Deep vein thrombosis
Deep vein thrombosis, or DVT, is a condition that occurs when a blood clot forms in one or more of the deep veins in your body — most often in the legs. DVT can develop if you have risk factors, keep legs fully flexed or haven’t moved for long periods of time, such as when traveling or bedridden.

DVT can develop if you have certain medical conditions that affect how your blood clots. It can be a serious condition because blood clots in your veins can break loose, travel through your blood stream and potentially lodge in your lungs, causing a pulmonary embolism. Use the following guidelines when documenting DVT:

• Code assignment is based solely on the provider’s specific description of the condition in the medical record.
• Code only confirmed cases of acute or current or chronic DVT using category I82.4 –.
• The condition in the medical record should be identified as acute or chronic:
  • I82.401 — Acute embolism and thrombosis of unspecified deep veins of right lower extremity
  • I82.501 — Chronic embolism and thrombosis of unspecified deep veins of right lower extremity
• A specific anatomic site where the thrombus is located should be identified (for example, right, left, bilateral, femoral vein, iliac vein, popliteal vein, tibial vein or other specified):
• I82.491 — Acute embolism and thrombosis of other specified deep vein of right lower extremity
• I82.702 — Chronic embolism and thrombosis of other specified deep vein of left upper extremity
• When DVT is completely resolved and the provider documentation indicates past history of DVT, assign a personal history code:
• Z86.718 — Personal history of other venous thrombosis and embolism
• Medical coders shouldn’t assign a code for DVT if the patient doesn’t have the condition.

Pulmonary embolism
An embolus is a blood clot that can occur in the veins of a body part, most commonly the legs. Emboli can dislodge and travel to other organs in the body. A pulmonary embolism is a clot that lodges in the lungs, blocking the pulmonary arteries and reducing blood flow to the lungs and heart. Document pulmonary embolisms as:

• I26.929 — Saddle embolus of pulmonary artery without acute cor pulmonale. Other pulmonary embolism without acute cor pulmonale
• This code includes acute pulmonary embolism and pulmonary embolism NOS.

Peripheral vascular disease
“Peripheral vascular disease” and “peripheral artery disease” are two terms used interchangeably. Provider progress notes may reference a physical exam of the lower extremity pulses or the ankle-brachial index, also known as ABI. Supporting documentation may also consist of claudication, pain, cramping or wounds that aren’t healing. Treatment may include anti-platelet medications, a walking exercise plan or surgical interventions. PVD is coded as:

• I73.9 — Peripheral vascular disease, unspecified

Tobacco use, diabetes, obesity, cardiovascular disease, hypertension, hyper lipidemia and physical inactivity are a few examples of risk factors and should also be clearly documented when present. When PVD is a manifestation of diabetes, it’s important the documentation ties the conditions together; assigning the correct combination code is equally important. Review the route below to find the proper diagnosis code using the ICD-10-CM:

• Locate the term “disease.”
• Locate the sub-term “vascular.”
• Under the sub-term, locate “peripheral.”
• In “diabetes mellitus,” see E08 to E13 with .51.

When coding conditions of the circulatory system, it’s important to review all documentation and follow the ICD-10-CM guidelines before assigning the appropriate code.

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.