Phlebitis and thrombophlebitis of right calf muscular vein

This code signifies inflammation of a vein in the right calf, specifically involving a muscular vein, accompanied by the formation of a blood clot (thrombus). This condition can cause pain, swelling, and tenderness in the affected area.

Apply this code when documentation explicitly states phlebitis or thrombophlebitis affecting a muscular vein in the right calf. This is typically supported by physical examination findings, ultrasound imaging confirming a thrombus, and patient symptoms localized to the right calf.

• Ensure the documentation specifies "muscular vein" and not just a general calf vein; otherwise, a more general code may be appropriate.
• Confirm laterality (right calf) is clearly documented.
• Consider sequencing this code after any underlying cause, such as trauma or malignancy, if applicable and documented.