Report Signs and Symptoms Unless DVT Is Confirmed
Question: A 58-year-old patient with a prior history of deep vein thrombosis (DVT) presents to their primary care physician (PCP) after noticing two days of increasing swelling, warmth, and aching pain in the right calf, similar to a prior resolved episode in their other leg. The provider writes “suspected DVT of lower right extremity” and sends the patient elsewhere for imaging as we don’t have that capability in our office. Should I code this as recurrent DVT? Codify Subscriber Answer: Remember, always code from the provider’s documentation. When reporting this encounter, the documentation mentions a prior history of DVT and new symptoms suggesting another DVT in the other leg, but the provider writes that the DVT is suspected rather than confirmed. Additionally, “recurrent” DVT implies that the condition has happened more than once, but that categorization also depends upon the provider’s documentation. Therefore, in this situation, if you’re coding according to the documentation, you’re coding signs and symptoms. The relevant codes may include: In this situation, the patient’s history of DVT is clinically relevant and can be included too, so don’t forget Z86.718 (Personal history of other venous thrombosis and embolism). Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
