Publication Date: 

A quick reference guide to assist with accurate, complete documentation and coding that reflects the true nature of a patient’s current health status at the highest level of specificity. Per ICD-10 official guidelines for reporting and coding “The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved.”  

Documentation & Coding Guidance 

Documentation needs to be clear and detailed using the following terms to allow accurate ICD10 code selection. Peripheral Vascular Disease (PVD) also referred to as Peripheral Artery Disease (PAD) is a broad term that refers to diseases of the blood vessels outside the heart and brain. Arteriosclerosis and atherosclerosis are used interchangeably for coding and documentation purposes. 


  • System: Arterial or Venous 
  • Vessel type: Native or graft (autologous, nonautologous biologic, nonautologous nonbiologic) 
  • Presence: include if there is ulceration, gangrene 
  • Anatomic location: include site, laterality 
  • Complicating factors: intermittent claudication, rest pain, ulceration, and gangrene 






Peripheral vascular disease, unspecified (PVD) 

  • includes Intermittent Claudication and peripheral artery disease, unspecified (PAD) 

Atherosclerosis of native arteries of the extremities 

  • Presence of ulceration or gangrene 

  • Intermittent Claudication 

Non-pressure chronic ulcer of lower limb, not elsewhere classified 

  • Important to avoid terms wounds, open wounds or lesion when documenting an ulcer 

  • Affected area 

  • Severity of ulcer 

Other disorders of arteries and arterioles 

  • Stricture, rupture, necrosis or dissection 

Phlebitis and thrombophlebitis 

  • Affected veins 


Aortic aneurysm and dissection  

  • Affected artery site  

  • With or without rupture or dissection 

Other aneurysm  

Vascular Disease and Diabetes  


Type 2 diabetes mellitus w/diabetic peripheral angiopathy without gangrene 

  • Assumed relationship between Diabetes Mellitus and vascular disease 



Type 2 diabetes mellitus w/diabetic peripheral angiopathy with gangrene 




Embolism and Thrombosis: Guidelines for Coding Pulmonary Embolism and Deep Vein Thrombosis