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Question: I have a report where the emergency department (ED) physician diagnosed the patient with lower extremity deep vein thrombosis (DVT). However, the radiology report findings state 鈥減roximal DVT鈥� or 鈥渙cclusion in the popliteal vein, femoral vein, iliac vein.鈥� Can I use the radiology report to specify the lower extremity DVT diagnosis as proximal?

South Carolina Subscriber

Answer: Yes, you can use the radiology report for further specificity. This additional information will help you choose the most accurate and appropriate diagnosis code for the patient鈥檚 condition.

Depending on whether the patient鈥檚 condition is acute or chronic, you鈥檒l look at the following code subcategories:

• I82.4Y- (Acute embolism and thrombosis of unspecified deep veins of proximal lower extremity)
• I82.5Y- (Chronic embolism and thrombosis of unspecified deep veins of proximal lower extremity)

Each of the above subcategories requires a 6^th character to complete the code. The 6^th character specifies laterality. Use 鈥�1鈥� for the right leg, 鈥�2鈥� for the left leg, 鈥�3鈥� for both legs (bilateral), or 鈥�4鈥� if the provider did not specify laterality.

The term 鈥減roximal鈥� means close to the body, and in this case that means the upper leg. At the same time, the popliteal, femoral, and iliac veins are all located within the upper legs.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC