Phlebitis and thrombophlebitis of left tibial vein

This diagnosis code signifies inflammation of the left tibial vein, accompanied by the formation of a blood clot within the inflamed vessel. This condition is a form of venous thrombosis affecting a specific deep vein in the lower leg.

Apply this code when documentation explicitly states phlebitis or thrombophlebitis localized to the left tibial vein. Supporting documentation includes imaging reports (e.g., ultrasound showing thrombus in the left tibial vein) and physician notes detailing symptoms like pain, swelling, and tenderness in the left lower leg consistent with this diagnosis.

• Ensure laterality is clearly documented (left vs. right).
• Distinguish from superficial thrombophlebitis, which has different code assignments.
• Code any associated pulmonary embolism separately if documented.