Mar. 11, 2022 Update: This communication has been edited to include two resource links.
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 Tips
Clearly document:
- Acuity
- Acute, new, and symptomatic thrombosis at the initiation of anticoagulation therapy
- Chronic, old or established thrombosis managed with ongoing anticoagulation therapy. Clearly state whether recurrent vs chronic.
- Historical, no longer has thrombosis/embolism, on prophylactic anticoagulant therapy
- Site/laterality
- Indicate provoked or unprovoked
- Pulmonary embolism: with or without cor pulmonale
- Anticoagulant therapy: clearly document if anticoagulant therapy is for treatment or for prophylaxis
| ICD-10 | Description | Example of when to use codes in this category |
| I82.xxx | Other Venous embolism thrombosis (4th, 5th, and 6th digits to describe location and acuity) | Patient seen for acute deep vein thrombosis of left lower extremity. Starting warfarin treatment. |
| Patient presents to primary care provider for management of chronic DVT of right femoral vein. | ||
| I26.xx | Pulmonary Embolism (Acute) | Patient seen for acute pulmonary embolism without cor pulmonale. To begin anticoagulation therapy. |
| I27.82 | Pulmonary Embolism (Chronic) | Patient presents for management of chronic pulmonary embolism and is currently on Eliquis. |
| Z86.711 | Personal history of pulmonary embolism | Patient with a history of a PE in 2015 |
| Z86.718 | Personal history of other venous thrombosis or embolism | Patient at coumadin clinic to have INR drawn. Previous DVT with no evidence of DVT on ultrasonic imaging. Remains on prophylactic coumadin. |
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