Case:  A 78 year old female is admitted to the hospital with GI bleeding. Past medical history includes deep vein thrombosis (DVT) for which she has had a Greenfield filter placed in the inferior vena cava (IVC) and been maintained on Xarelto for 2 years. She underwent EGD and colonoscopy and her bleeding subsided after Xarelto was temporarily discontinued.

What is the proper coding of deep vein thrombosis as a secondary diagnosis in this case?

Answer:

When to code acute, chronic or history of DVT can be challenging. Acute DVT is usually treated with heparin‐type medications for immediate anticoagulation to prevent further clot growth while a transition is made to long‐term (3‐12 months) Coumadin, or more recently Xarelto, to prevent recurrent DVT. These medications do not "treat" the acute DVT. The acute blood clots in deep veins are usually dissolved spontaneously by endogenous processes in the veins within a few days, not by heparin, Coumadin or Xarelto.

The acute episode of DVT ends when the patient is stabilized, transitioned to Coumadin or Xarelto and discharged. If such a patient is admitted without a recurrent episode of DVT, the correct status is "History of DVT", not acute or chronic DVT. A subsequent episode of DVT requiring admission would constitute a recurrent episode of acute DVT.

Chronic DVT is a situation in which one or more recurrent acute episodes have occurred. Chronic life‐long anticoagulation is usually recommended after the first recurrent episode, and also after the initial episode for patients with certain underlying clotting disorders.

When recurrent episodes of DVT become "chronic" is a subjective decision requiring physician determination. Factors to be considered are the number and frequency of episodes, and the need for life‐long anticoagulant therapy. Insertion of a Greenfield (IVC) filter is often utilized for chronic DVT.

In this case example, the patient has chronic DVT (not simply history of DVT) because she is being treated chronically with Xarelto for more than 12 months and would be expected to remain on life-long Xarelto. Placement of a Greenfield (IVC) filter is another indicator of chronic DVT. Unspecified DVT should not be assigned in this situation since it would incorrectly default to the acute DVT code.  If documentation is unclear, a query should be submitted to confirm chronic DVT.

The distinction between acute and chronic DVT is very important since acute DVT is one of the Medicare patient safety indicators (PSI) considered an adverse complication having a negative impact on quality of care and pay for performance measures.