Phlebitis and thrombophlebitis of right tibial vein

This code signifies the presence of inflammation of the right tibial vein, accompanied by the formation of a blood clot within that vein. This condition is a form of deep vein thrombosis (DVT) affecting a specific lower extremity vessel.

Apply this code when documentation explicitly states thrombophlebitis or phlebitis of the right tibial vein. This is typically diagnosed through imaging studies like duplex ultrasound confirming a thrombus in the right tibial vein, often presenting with pain, swelling, and tenderness in the lower leg.

• Ensure laterality (right) is clearly documented.
• Distinguish from superficial thrombophlebitis, which has different code assignments.
• Consider additional codes for any associated complications, such as pulmonary embolism (I26.-).